mLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX64066975 
RD540  B19  1914-1917  Surgicalwe[sj9i 

RECAP 


/f^-r^^ 


Bf9 


Columbia  53nit)em'tp 

intljfCttpofl^eujgork 

College  of  ^i^psiictang  anb  burgeons 
SLibrarp 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgicalpapers1900bald 


SURGICAL  PAPERS 

(1914-1917) 
By 

J.  F.  BALDWIN,  A.M.,M.D.,F.A.C.S. 

COLUMBUS,  OHIO 

Surgeon  to  Grant  Hospital;  Fellow  American  Association  of  Obstetricians 

and  Gynecologists;  Fellow  American  Medical  Association, 

Ohio  State  Medical  Society,  etc. 


Xftrous  Oxide-Oxygen   (Paper  in  full) Page     3 

The  most  dangerous  anesthetic  in  use  for  major  operations.  Its 
exploitation  chiefly  for  pecuniary  gain  and  advertising.  Dis- 
honesty  of   anesthetists.      A    "conspiracy   of    silence." 

Explanatory  Note  on  Same..— Page  14 

Demand  for  Publicity  of  Nitrous-Oxide  Deaths Page  15 

Shockless  Operations  Page  17 

Absence  of  shock  due  to  control  of  hemorrhage,  efficiency  of 
the  operator,  and  gentleness  of  -manipulation;  not  to  any  be- 
numbing of  the  field  of  operation  by  local  anesthetics.  "Anoci- 
association"  an  interesting  hypothesis. 

Technique  of  Abdominal  Hysterectomy Page  28 

Description  of  the  author's  method,  evolved  from  an  experi- 
ence  of   over   2000  hysterectomies. 

Puerperal  Thrombo-Phlebitis  Page  37 

Operative  intervention  gives  a  very  favorable  prognosis ;  medical 
treatment  practically  useless. 

Dermoids   of  Kidney : Page  40 

Report  of  all  reported  cases — five,  with  one  of  the  author's. 

Splenectomy  for  Pernicious  Anemia Page  43 

Cesarean  Section  for  Unusual  Indication Page  44 

Four  Cases  of  "Acute  Abdomen" Page  45 

Four   carefully   made   autopsies,   with    no   cause   of   death    found. 


o  ■  .  T^T)  c^.-, 


en 


CO 


^  FOREWORD. 

In  1914,  I  published  a  little  booklet  containing  reprints  of  a  num- 
ber of  articles  which  I  had  published  in  different  medical  journals 
during  the  few  preceding  years,  and  certain  conclusions  drawn  from 
my  work  which  was  based  at  that  time  on  something  more  than 
-8,500  abdominal  sections.  During  the  three  years  since  that  publi- 
cation I  have  added  to  my  experience  by  2,106  abdominal  sections, 
making  a  total  of  nearly  11,000  such  operations. 

When  a  surgeon  operates  in  a  public  clinic,  his  personal  examin- 
ation of  cases  brought  before  him  is  usually  only  cursory,  and  the 
after  treatment  of  his  cases  is  left  to  house  doctors.  In  my  own 
work,  however,  with  a  few  negligible  exceptions,  the  history  of  rhe 
patient  is  obtained  personally;  the  examination  and  diagnosis  are 
reached  personally,  though  many  times  with  the  co-operation  of 
associates  to  whom  are  entrusted  investigations  along  special  liijcs 
— such  co-operation  being  many  times  of  the  greatest  importance  in 
the  elucidation  of  the  case;  and  the  oversight  of  the  patients  during 
convalescence  is  entirely  in  my  own  hands,  so  that  my  knowledge 
of  each  case  from  start  to  finish  is  unusually  complete,  and  my  notes 
of  the  cases  unusually  full.  The  conclusions,  therefore,  formed  after 
such  a  large  experience,  and  with  such  personal  knowledge  of  the 
cases,  must  necessarily  be  worthy  of  more  consideration  than  would 
conclusions  drawn  from  imperfect  personal  knowledge  and  the  usual 
incomplete  hospital  records. 

For  a  number  of  years  I  have  been  in  the  habit  of  sending  out  re- 
prints only  after  a  number  of  my  articles  have  appeared  in  the  medi- 
cal press,  instead  of  sending  them  out  singly  as  is  the  general  custom. 
Recipients  of  these  reprints  have  frequently  expressed  a  preference 
for  this  method,  and  hence  I  again  employ  it. 

In  sending  out  this  contribution  I  would  call  the  attention  of  the 
general  practitioner  especially  to  the  article  on  anoci-association,  un- 
der the  heading  of  "Shockless  Operations,"  and  also  to  the  article 
showing  the  great  danger  of  nitrous  oxide-oxygen  anesthesia,  which 
method,  for  reasons  stated,  is  being  at  the  present  time  so  widely 
and  dishonestly  exploited.     Abdominal  surgeons  will  be  particularly 


interested  in  the  illustrated  article  on  the  Technique  of  Abdominal 
Hysterectomy,  evolved  as  it  is  from  such  a  large  number  of  cases. 

'  Since  my  publication  in  1914,  I  have  seen  no  reason  to  change  my 
views  as  to  the  use  of  ether  as  the  standard  anesthetic ;  as  to  the 
method  of  sterilizing  infected  surfaces  by  the  use  of  iodine;  as  to 
the  material  for  ligatures ;  as  to  the  extreme  impropriety  of  purga- 
tion in  anything  which  may  possibly  be  a  beginning  appendicitis ; 
as  to  the  use  of  water  and  opiates  b}^  patients,  and  as  to  the  character 
of  drainage  when  drainage  is  necessarv. 

J.  F.  B. 


NITROUS  OXIDE-OXYGEN,  THE  MOST  DANGEROUS 

ANESTHETIC 

Whenever  any  new  line  of  treatment  is  proposed  it  is  universally  recog- 
nized as  incumbent  upon  its  sponsors  to  show  that  it  is  better  than  pre- 
vailing lines  of  treatment,  its  superiority  consisting  in  a  larger  percentage 
of  cures,  a  more  prompt  recovery,  or  a  diminution  of  morbidity. 

This  rule  most  certainly  should  apply  to  the  introduction  of  any  new 
anesthetic  agent.  Chloroform  has  its  advocates,  and  for  certain  purposes 
its  advantages,  but  ether  may  be  accepted  as  the  standard  of  safety  the 
world  over.  Every  new  anesthetic  must,  therefore,  be  weighed  in  the 
balance  with  ether. 

If  the  sponsors  of  the  new  anesthetic  are  actuated  purely  by  scientific 
motives,  every  unsatisfactory  experience,  and  certainly  every  death, 
would  be  promptly  reported,  so  that  the  profession  at  large  could  judge 
as  to  the  relative  value  of  the  new  anesthetic ;  while  if  such  adverse  expe- 
riences are  not  reported,  but  attempts  are  even  made  to  cover  up  and  deny 
their  occurrence,  then  only  mercenary  motives  can  be  attributed  to  the 
advocates. 

[Within  a  few  years  the  profession  has  been  hearing  much  of  nitrous 
oxide-oxygen,  but  the  sponsors  for  this  new  anesthetic  have  displayed  a 
notorious  and  significant  failure  to  report  their  deaths,  while  the  amount 
of  advertising  which  the  method  has  received  in  the  daily  papers,  and 
the  large  fees  which  are  charged  by  the  anesthetists  for  its  use,  have 
created  more  than  a  suspicion  that  many  of  them  at  least  are  actuated  by 
motives  that  are  far  from  altruistic]  Teter  of  Cleveland,  in  a  personal 
letter,  reports  that  he  knows  of  twenty-six  nitrous  oxide-oxygen  fatalities, 
nine  of  which  have  occurred  in  Cleveland.  Dr.  A.  H.  Miller  of  Prov- 
idence, R.  I.,  has  collected  references  to  eighteen  deaths.  Rovsing  was 
able  to  get  track  of  thirteen  deaths,  several  of  which  had  been  suppressed. 
(This  author  in  his  chapter  on  anesthesia  gives  a  death  rate  of  one  in 
2,000  for  chloroform,  and  one  in  50,000  for  ether.)  Gwathmey  (personal 
communication)  knows  of  from  twenty  to  forty  unreported  deaths. 

Practically  all  of  the  anesthetists  who  have  written  on  nitrous  oxide- 
oxygen  state  most  positively  that  death  occurs  only  from  asphyxia,  and 
that  if  the  anesthetist  watches  the  color  and  pushes  the  oxygen  death  can- 
not occur.  If  that  is  the  case,  it  is  certainly  very  important  that  the 
anesthetist  shall  know  what  are  the  symptoms  that  indicate  asphyxia. 

3 


Turning  to  Gwathmey  (p.  134)  we  find  the  following  statement:  "The 
fourth  stage,  or  stage  of  overdose,  supervenes  through  some  error  of 
technique  by  which  asphyxia  becomes  the  predominant  feature  of  the 
narcosis.  Breathing  becomes  embarrassed  usually  through  convulsive 
muscular  spasm.  The  interference  with  respiration  is  first  marked 
through  hyperpnea  (excessive  breathing),  then  by  dyspnea  (difficult 
breathing).  Violent  or  convulsive  expiratory  efforts,  sometimes  accom- 
panied by  general  muscular  spasms,  mark  the  second  stage  of  asphyxia. 
Following  this  there  is  a  stage  of  exhaustion,  in  which  the  muscular 
spasm  is  superseded  by  muscular  flaccidity.  The  pupils  become  more 
widely  dilated,  the  lids  are  widely  open,  the  conjunctivae  are  insensi- 
tive, the  pulse  becomes  imperceptible,  respiration  is  marked  by  prolonged 
sighing  inspirations  which  gradually  cease.  Paralysis  of  the  respiratory 
center  is  complete  and  death  supervenes.  Marked  cyanosis  accompanies 
this  condition  of  affairs." 

In  none  of  the  cases  detailed  in  this  paper  was  death  the  result  in  any 
way  whatever  of  asphyxia,  but  in  all  of  them  the  death  occurred  without 
warning,  in  the  midst  of  an  apparently  smooth  anesthesia,  and  with  the 
startling  suddenness  of  an  overdose  of  chloroform. 

Gwathmey  states,  as  the  natural  effect  of  nitrous  oxide-oxygen  admin- 
istration, that  the  pulse  becomes  rapid,  from  140  to  160  per  minute,  and 
in  prolonged  operations  the  temperature  goes  up  from  ^  to  2  degrees 
(p.  109). 

According  (Gwathmey)  to  the  experiments  of  Buxton,  and  later  of 
Wood  and  Cerna,  "nitrous  oxide-oxygen  exerts  a  direct  action  upon  the 
heart  itself,  having  little  or  no  direct  influence  upon  the  vasomotor  centers 
of  the  brain  cortex"  (p.  130) .  "Buxton  .  .  .  found  that  .  .  . 
nitrous  oxide  produced  so  great  an  enlargement  (of  the  bulk  of  the  brain 
and  the  cord)  as  to  force  out  the  cerebrospinal  fluid"  (p.  131). 

"The  most  natural  inference,  from  the  study  of  the  reflexes  and  other 
efifects  upon  the  nervous  system,  is,  according  to  Kemp,  that  nitrous 
oxide  acts  especially  upon  the  brain  cortex"    (p.  131). 

It  is  inconceivable  to  think  that  any  agent  capable  of  producing  the 
constitutional  disturbances  indicated  above  should  not  be  pregnant  with 
manifold  possibilities  of  evil;  and  yet,  in  a  calendar  just  received  from  a 
[Cleveland]  manufacturer  of  nitrous  oxide-oxygen,  we  are  told  that  this 
combination  "Does  not  affect  the  heart ;  does  not  affect  the  kidneys ;  does 
not  produce  nausea ;  decreases  danger  of  postoperative  pneumonia." 

[A  few  months  ago  there  was  inserted  at  my  request  a  notice  in  the 
Journal  of  the  American  Medical  Association,  asking  for  reports  of 
fatalities  under  nitrous  oxide-oxygen,  and  the  same  notice  was  repro- 
duced in  the  Ohio  State  Medical  Journal.     Those  who  are  informed  as 


to  the  secrecy  which  seems  to  be  generally  maintained  among  nitrous 
oxide-oxygen  anesthetists,  will  not  be  surprised  when  I  state  that  I  have 
not  yet  received  a  single  reply  to  either  of  these  notices.  /  had  not  ex- 
pected any.] 

Connell,  who  writes  the  article  on  anesthesia  in  Johnson's  new  work 
on  "Operative  Therapeusis,"  says  of  the  nitrous  oxide-oxygen  anesthesia 
that  "since  the  extensive  introduction  of  this  gas  into  general  surgery, 
the  reported  and  unreported  deaths  have  probably  far  exceeded  those 
from  ether,"  and  aside  from  its  death  rate  it  is  evident  from  his  entire 
chapter  on  this  subject  that  he  regards  its  disadvantages  as  far  outweigh- 
ing its  possible  advantages. 

Luke,  anesthetist  to  St.  Luke's  Hospital,  New  York,  reports  one  death 
out  of  about  200  administrations  of  nitrous  oxide-oxygen.  The  patient 
was  dead  six  minutes  after  entering  the  operating  room.  He  also  reports 
another  case  in  which  the  patient  was  resuscitated  with  great  difficulty. 
Dr.  Roy  McClure,  now  of  the  Johns  Hopkins,  reports  to  me  two  deaths 
which  occurred  while  he  was  connected  with  the  New  York  Hospital. 
These  occurred  in  the  service  of  Dr.  Frank  Hartley,  and  took  place  while 
gas  was  being  given  as  a  preliminary  to  ether.  Dr.  McClure  was  resi- 
dent surgeon  at  this  time,  and  is  entirely  familiar  with  the  facts. 

From  inquiry  as  to  nitrous  oxide-oxygen  at  the  Mayo  clinic,  I  find  that 
this  anesthetic  was  used  in  about  1,400  cases  as  a  preliminary  to  ether. 
I  can  learn  of  no  mortality,  but  the  result  was  not  satisfactory  and  it  was 
dropped.  Miss  Henderson,  the  anesthetist,  under  date  of  January  16,  1915, 
wrote  that  on  the  day  before  Dr.  E.  J.  Burch  of  Carthage,  Mo.,  reported 
to  her  a  case  which  he  had  lost  under  nitrous  oxide-oxygen.  The  anes- 
thesia had  been  a  brief  one  for  a  rectal  examination.  The  examination 
was  completed  and  the  surgeon  left  the  room,  but  was  called  back  hur- 
riedly and  found  the  patient  dead.  She  says  of  the  nitrous  oxide-oxy- 
gen anesthesia :  "We  have  investigated  its  merits  at  various  times, 
but  the  surgeons  have  riot  seen  fit  to  make  any  change  from  'drop  ether/ 
which  has  been  used  here  for  many  years."  A  personal  communication 
from  Dr.  Burch  affirms  this  report. 

In  conversation  recently  with  two  of  the  best  known  surgeons  of  Cleve- 
land, Drs.  Bunts  and  Skeel,  I  found  that  no  thorough  investigation  of 
nitrous  oxide-oxygen  deaths  had  ever  been  made  in  that  city;  numerous 
instances  were  known,  but  the  details  had  never  been  published.  Both 
of  these  surgeons  used  ether  by  preference,  but  because  of  the  newspaper 
prominence  given  nitrous  oxide-oxygen  they  were  obliged  in  some  cases 
to  yield  to  the  request  of  their  patients  and  use  that  anesthetic.  [Under 
such  circumstances  they  always  insisted  that  Dr.  Teter  should  be  secured 
to  give  the  anesthetic] 

5 


Gwathmey  (p.  109)  reports  three  fatalities  out  of  2,500  cases.  In  the 
first  case  death  occurred  suddenly  before  operation  was  commenced.  In 
the  second  it  also  occurred  suddenly,  but  the  operation  had  begun  and  the 
anesthesia  up  to  that  point  had  been  normal.  In  the  third  case  the  pulse 
became  very  rapid,  and  at  the  close  of  the  operation  went  up  very  rapidly. 
Color  became  cyanotic  and  could  not  be  cleared  up  with  oxygen,  the 
breathing  became  weaker  and  weaker  and  finally  ceased.  Because  at  the 
autopsy  an  enlarged  thymus  was  found,  with  hypertrophy  of  the  lym- 
phatic tissues  in  general,  the  pathologist  gave  status  lymphaticus  as  the 
cause  of  death. 

Recently  (December  5,  1915)  Dr.  T.  G.  McCormick,  now  of  Ports- 
mouth, Ohio,  formerly  of  Detroit,  told  me  that  they  had  had  either  seven 
or  eight  deaths  at  Grace  Hospital,  Detroit.  He  was  resident  physician 
there  during  that  time,  and  one  of  the  deaths  occurred  while  he  was 
giving  the  anesthetic.  He  could  give  no  particulars  of  any  of  the  other 
cases,  but  his  own  patient  died  suddenly  and  without  any  warning. 

The  following  is  the  Columbus  death  list  for  nitrous  oxide-oxygen : 

1.  The  first  death  in  Columbus  from  nitrous  oxide  alone  occurred 
some  years  ago  at  the  Dental  Clinic  of  the  Ohio  Medical  University. 
The  gas  was  given  for  the  extraction  of  teeth,  and  the  patient  died  sud- 
denly and  without  any  warning.  Efforts  at  resuscitation  were  made  as 
usual,  but  were  unavailing.  My  authority  is  Dr.  A.  O.  Ross,  then  dean 
of  the  dental  department. 

2.  Probably  the  first  death  in  this  city  from  nitrous  oxide-oxygen 
took  place  at  Mt.  Carmel  Hospital,  the  anesthetist  being  a  physician  who 
was  considered  an  expert,  and  who  is  among  the  best  known  anesthetists 
of  New  York  City.  The  patient,  according  to  the  anesthetist's  statement 
to  me,  died  suddenly  in  the  midst  of  a  somewhat  prolonged  abdominal 
operation. 

3.  Dr.  G.  W.  Mosby,  of  Columbus,  reports  to  me  that  he  had  a  patient 
die  from  nitrous  oxide-oxygen,  also  at  Mt.  Carmel  Hospital,  the  anes- 
thetic in  that  case  being  given  by  Dr.  Jones.  The  operation  was  for  pel- 
vic infection.  The  operation,  he  says,  had  lasted  about  forty-five  minutes, 
and  was  proceeding  satisfactorily  apparently,  when  the  patient  suddenly 
died.     He  unhesitatingly  attributes  the  death  to  the  anesthetic. 

4.  Dr.  R.  B.  Drury  reports  that  last  year  at  the  St.. Clair  Hospital  a 
woman  was  being  put  under  nitrous  oxide-oxygen  anesthesia  by  Dr. 
Jones  for  the  removal  of  a  fibroid  by  the  late  Dr.  Leach,  whom  Dr. 
Drury  was  assisting.  Just  at  the  beginning  of  the  incision  the  woman 
suddenly  expired  without  the  slightest  warning. 

5.  Dr.  Drury  also  reports  a  death  from  nitrous  oxide-oxygen  in  a 
man  aged  65,  whom  he  operated  upon  at  Washington  Courthouse.     A 

6 


year  before  the  same  patient  had  had  a  suprapubic  prostatectomy  un- 
der ether  by  the  late  Dr.  Leach,  and  went  through  the  operation  nicely. 
Further  trouble  coming  on,  Dr.  Drury  decided  to  operate  through  the  per- 
ineum. Nitrous  oxide-oxygen  was  given  by  Dr.  Rice.  In  the  midst  of  the 
operation,  which  had  been  going  on  all  right,  the  patient  suddenly  expired. 

6.  Dr.  George  Williams  reports  that  at  the  St.  Clair  Hospital  he  gave 
nitrous  oxide-oxygen  for  a  hysterectomy  for  fibroid  turnor,  about  one 
year  ago.  The  patient  went  through  the  operation  very  satisfactorily, 
and  the  surgeon  was  about  to  close  the  incision  when  the  patient  suddenly 
died  without  any  warning  whatever ;  had  been  doing  well  up  to  that 
moment. 

7.  Dr.  G.  L.  Saunders  tells  me  that  about  four  years  ago,  while  wait- 
ing for  a  patient  of  his  own  to  be  operated  upon  at  Mt.  Carmel,  he  wit- 
nessed an  operation  on  a  colored  woman,  probably  35  years  of  age,  who 
was  suffering  from  a  small  fibroid.  Nitrous  oxide-oxygen  was  being 
given,  and  just  as  the  abdomen  was  being  opened,  and  before  any  work 
on  the  inside  had  commenced,  the  patient  suddenly  died  without  any 
warning.  All  efforts  at  resuscitation  failed.  Dr.  Saunders  was  a  stranger 
in  the  city,  and  did  not  know  the  anesthetist. 

8.  Dr.  Goodman  reports  that  on  March  13,  1913,  he  opened  through 
the  vagina  a  cul-de-sac  abscess.  The  case  was  a  puerperal  one  of  two 
week's  standing.  Nitrous  oxide-oxygen  anesthesia  was  given  by  Dr. 
Rice.  The  opening  of  the  abscess  took  but  a  mornent,  but  the  patient 
suddenly  died  on  the  table. 

9.  Dr.  Goodman  reports  the  case  of  a  young  woman,  mother  of  a  child 
two  years  of  age,  upon  whom  he  operated  for  the  removal  of  fibroids. 
The  husband,  against  the  wishes  of  the  surgeon,  insisted  on  the  use  of 
nitrous  oxide-oxygen.  A  supravaginal  hysterectomy  was  made  in  the 
usual  way,  the  operation  being  exceedingly  easy.  There  were  no  adhes- 
ions, and  the  operation  took  about  twenty  minutes.  The  patient  had 
taken  the  anesthetic  beautifully,  breathing  quietly,  and  with  good  color. 
As  the  last  stitch  was  being  inserted  the  patient  ceased  to  breathe  and 
the  heart  stopped.  Dr.  Rice  was  giving  the  anesthetic.  Dr.  Goodman 
at  once  opened  the  abdomen,  massaged  the  heart  through  the  diaphragm, 
giving  deep  injections  into  the  heart  of  adrenalin,  besides  using  oxygen 
and  artificial  respiration,  dilating  the  sphincter  ani,  etc.,  but  the  patient 
was  dead, 

10.  This  patient  was  a  woman  operated  upon  by  Dr.  Howell  for 
abdominal  tumor.  She  had  had  one  kidney  removed  some  time  before, 
and  was  known  to  be  suffering  from  nephritis.  Nitrous  oxide-oxygen 
was  used.  After  the  operation  there  was  bloody  urine,  then  suppression 
of  urine,  then  death  from  uremia.     (Had  this  suppression  of  urine  oc- 

7 


curred  under  ether,  the  death  would  undoubtedly  have  been  attributed 
to  the  ether ;  by  a  parity  of  reasoning  it  should  be  attributed  to  the  nitrous 
oxide-oxygen,  though  it  is  possible  that  the  anesthetic  had  nothing  to  do 
with  the  death.) 

11.  Dr.  J.  M.  Thomas  reports  that  about  two  years  ago  Dr.  Howell 
operated  upon  a  patient  of  his,  22  years  of  age,  for  chronic  appendicitis ; 
had  suffered  from  infantile  paralysis,  and  had  some  functional  heart 
trouble.  Dr.  Rice  gave  the  anesthetic.  The  operation  was  completed, 
and  Dr.  Howell  had  left  the  room,  when  suddenly  the  patient  went  bad, 
and  apparently  died  on  the  table.  Dr.  Fletcher  and  several  others  were 
present.  Artificial  respiration  was  kept  up,  he  says,  for  just  sixty  min- 
utes, when  she  breathed  herself  for  about  ten  minutes.  The  abdomen 
had  been  reopened  by  Dr.  Howell,  the  heart  massaged,  and  adrenalin 
injected  into  the  heart  substance.  After  breathing  for  ten  minutes  respi- 
ration stopped  and  further  resuscitation  was  impossible.  He  is  positive 
that  the  death  was  due  to  nitrous  oxide-oxygen. 

12.  Mrs.  McC,  aged  37,  had  a  simple  abdominal  hysterectomy  Octo- 
ber 28,  1914.  In  spite  of  my  own  protests  and  those  of  her  attending 
physician,  she  insisted  on  taking  nitrous  oxide-oxygen.  Dr.  Rice  ad- 
ministered the  anesthetic,  which  she  took  beautifully,  but  just  at  the  com- 
pletion of  the  abdominal  work,  without  the  slightest  warning,  the  heart's 
action  suddenly  ceased  and  the  patient  was  dead.  The  heart  was  at  once 
massaged  through  the  open  abdomen,  and  all  the  usual  measures  for  re- 
suscitation instituted,  but  in  vain, 

13.  Mr.  B.  of  Degraff,  aged  62,  was  operated  upon  February  26,  1914; 
had  been  having  severe  attacks  of  pain  in  the  region  of  the  gall  bladder, 
and  his  physicians  thought  that  he  had  passed  gall  stones.  He  had  had 
some  bronchorrhea  for  several  years;  no  kidney  trouble.  Because  of 
the  history  and  local  conditions  a  gall-bladder  operation  was  advised,  and 
because  of  the  bronchorrhea  I  advised  nitrous  oxide-oxygen.  There  was 
hypertrophy  of  the  heart,  but  no  valvular  lesion  could  be  detected.  Pulse 
regular,  and  of  good  volume.  The  diagnosis  was  a  matter  of  doubt, 
but  malignancy  could  not  be  positively  excluded.  An  incision  was  made 
over  the  gall  bladder,  which  was  found  distended.  At  this  time  the 
patient  was  reported  by  Dr.  Rice  to  be  doing  badly,  and  an  instant  ex- 
amination showed  a  pulseless  aorta.  The  heart  was  at  once  massaged 
through  the  diaphragm,  artificial  respiration  kept  up,  etc.,  but  all  efforts 
were  without  avail.  Autopsy  showed  an  enlarged  heart,  but  no  dilata- 
tion. 

14.  Mr.  L.,  aged  62,  was  brought  to  the  hospital  May  14,  1912,  with 
a  diagnosis  of  peritonitis  from  appendicitis.  His  condition  when  he 
reached  the  hospital  was  bad,  as  he  had  got  chilled  on  the  train  coming 

8 


up.  In  the  course  of  an  hour  this  condition  improved,  so  that  he  had  a 
good  color,  and  a  good  heart's  action.  His  condition  was  such  as  to 
indicate  extensive  infection,  and  I  planned  to  make  a  quick  incision  and 
put  in  a  drain.  For  this  purpose  I  thought  nitrous  oxide-oxygen 
safer  than  ether.  He  took  it  nicely,  but  just  as  the  incision  was  made 
he  died  suddenly.  After  death  was  determined  the  incision  was  extended 
somewhat,  and  it  was  then  found  that  there  had  been  a  plugging  of  the 
superior  mesenteric  artery,  all  the  intestines  supplied  by  the  artery  being 
black  and  devitalized.  Of  course,  death  would  have  occurred  within  a 
few  days,  so  that  the  anesthetic  death  was  of  no  special  importance. 
Within  a  few  months  of  this  time,  however,  I  had  two  similar  cases,  one 
in  a  young  woman  of  about  30,  the  other  in  a  man  of  about  60.  Ether  was 
given  in  both  cases,  the  abdomen  opened,  the  condition  determined,  and 
the  abdomen  at  once  closed.  Both  survived  the  exploration  by  a  day 
or  two. 

The  above  list  shows  that  we  have  had  twelve  or  more  properly  per- 
haps thirteen,  deaths  from  nitrous  oxide-oxygen  when  given  for  major 
operations.  Careful^  investigation  seems  to  show  that  there  have  been 
not  to  exceed  twelve  or  thirteen  hundred  administrations  of  this  anes- 
thetic for  major  operations,  in  Columbus,  so  that  the  death  rate  has  been 
practically  1  per  cent. 

[That  some  patients  have  had  narrow  escapes  from  death  is  shown 
by  several  cases  that  have  been  reported  to  me.  Thus  Dr.  Kahn,  of  our 
local  Board  of  Health,  reported  a  case  in  which  a  stout,  healthy  man  was 
being  operated  upon  for  a  simple  perineal  abscess.  The  anesthetic  was 
being  given  by  Dr.  I.  W.  Jones,  a  dentist,  who  claims  to  have  had  a  very 
large  and  entirely  successful  experience  as  a  nitrous  oxide-oxygen  anes- 
thetist. The  patient  suddenly  went  to  the  bad,  according  to  Dr.  Kahn, 
and  all  thought  that  death  was  certain,  but  he  finally  rallied  and  survived. 
Dr.  Andrews  Rogers  reports  a  case  which  he  saw  at  Mt.  Carmel,  the 
nitrous  oxide-oxygen  in  that  case  being  given  by  the  same  adminis- 
trator. The  patient  seemed  to  be  doing  well,  when  suddenly  she  ceased 
to  breathe  and  was  apparently  dead.  After  twenty  minutes  of  vigorous 
effort  at  resuscitation  she  rallied.  The  doctor  looked  at  his  watch  and 
knows  the  exact  time  consumed.  Dr.  J.  E.  Brown,  one  of  our  leading 
specialists,  tells  me  that  he  has  used  nitrous  oxide  oxygen  in  about  eight 
cases  for  the  removal  of  tonsils  and  adenoids,  Dr.  Jones  being  in  each 
case  the  anesthetizer.  Some  of  these  had  been  given  at  the  Protestant 
Hospital,  the  others  in  his  own  office.  He  found  the  anesthesia  very 
unsatisfactory,  the  patient  being  so  awake  as  to  feel  the  pain  and  suffer 
accordingly,  or  so  cyanosed  as  to  be  apparently  in  imminent  danger  of 
death.    Dr.  I.  B.  Harris  states  that  nitrous  oxide-oxygen  had  been  given, 

9 


so  far  as  he  can  learn,  but  once  at  St.  Francis  Hospital,  the  surgeon 
being  the  late  Dr.  Barnhill.  He  quotes  the  Sister  as  saying  that  while 
death  on  the  table  seemed  imminent,  the  patient  managed  to  get  out 
alive.    Dr.  Jones  was  the  anesthetist.] 

Without  persistent  effort  on  my  part,  few  of  the  nitrous  oxide-oxygen 
deaths  in  Columbus  would  have  been  unearthed.  I  have  made  no  canvass 
of  the  situation  in  other  cities  of  the  State,  but  incidentally  know  of 
several  deaths  in  Cincinnati,  Cleveland,  Toledo,  and  Akron.  In  one  of 
the  Cincinnati  cases  the  anesthetist  was  a  specialist  of  twenty  years' 
experience,  who  had  spent  two  weeks  at  Lakeside  to  familiarize  himself 
with  the  details  of  the  nitrous  oxide-oxygen  anesthesia.  He  had  admin- 
istered the  combination  successfully  in  a  number  of  cases,  but  in  this 
particular  case  (nephrotomy  for  stone)  he  had  objected  to  the  giving 
of  the  gas  as  he  preferred  ether,  but  the  surgeon  insisted  and  he  com- 
plied. The  anesthesia  went  off  beautifully,  the  operation  had  lasted 
about  thirty  minutes,  and  was  just  about  completed  when  the  patient 
suddenly  died.  (Personal  communication  from  the  anesthetist,  Dr.  Leroy 
S.  Colter.) 

Under  date  of  June  1,  1916,  in  response  to  a  letter  of  inquiry  following 
a  newspaper  announcement.  Dr.  H.  H.  Wiggers  of  Cincinnati  writes 
me  that  the  death  of  a  married  woman  in  his  practice  "occurred  suddenly, 
without  any  warning.  There  was  simply  a  cessation  of  the  heart  beat. 
We  cannot  account  for  the  death."  No  details  of  operation  given,  but 
the  anesthetist  was  a  specialist,  with  an  experience  of  about  eleven  hun- 
dred cases  of  nitrous  oxide-oxygen  anesthesia. 

Gwathmey,  concerning  whose  skill  and  experience  there  can  be  no 
doubt,  under  date  of  November  6,  1915,  gives  me  a  personal  report  of  a 
death  which  he  had  had  a  few  days  before,  and  which  he  expects  to 
report  at  an  early  date.  This  death  under  nitrous  oxide-oxygen,  he  says, 
"was  absolutely  uncalled  for,  and  has  changed  my  ideas  of  the  safety  of 
nitrous  oxide-oxygen  entirely.  ...  I  believe  if  I  had  given  him 
ether  the  man  would  have  been  alive  today." 

In  commenting  on  autopsy  No.  3394,  Dr.  Hugh  Cabot,  of  the  Massa- 
chusetts General  Hospital  ("Case  Reports"  received  January  16,  1916), 
says  in  regard  to  a  death  from  nitrous  oxide-oxygen,  that  "during  the 
operation  the  anesthetist  remarked  that  the  breathing  was  slow,  but  the 
color  of  the  skin  normal.  The  color  of  the  blood  was  at  no  time  ob- 
served to  be  unusual.  At  the  point  last  described  the  anesthetist  ob- 
served that  the  respiration  had  stopped.  Artificial  respiration  was 
started  and  kept  up  for  forty  minutes  steadily,  with  the  liberal  use  of 
oxygen.  .  .  .  This  was  an  anesthetic  death  due  to  gas  and  oxygen 
anesthesia."     The  anesthetist  in  this  case  was  Dr.  Freeman  Allen,  chief 

10 


of  the  department  of  anesthesia,  and  consulting  anesthetist  to  the  Massa- 
chusetts General  Hospital  and  Children's  Hospital. 

Ochsner  says  that  he  made  a  careful  test  with  one  hundred  successive 
cases  of  nitrous  oxide  anesthesia,  compared  with  a  similar  number  of 
ether  anesthesias  by  the  drop  method.  He  says  he  "found  no  difference 
in  the  course  of  the  anesthesia,  nor  in  the  comfort  of  the  patient,  but 
there  was  a  little  more  bronchial  irritation  following  operation  -when 
nitrous  oxide-oxygen  gas  had  been  used."  (Absence  of  bronchial  irritation 
is  one  of  the  strong  claims  made  by  those  who  advise  this  anesthetic.) 
The  method,  he  says,  he  found  cumbersome,  and,  therefore,  perma- 
nently abandoned  it.  The  only  special  value  that  he  attributed  to  it  is  a 
"slight  advertising  value  which  the  method  undoubtedly  possesses."  He 
then  speaks  of  the  addition  of  oxygen  to  the  nitrous  oxide  gas,  and 
claims  for  it  the  same  advertising  value  as  for  the  other,  but  "possibly 
to  a  somewhat  greater  degree."  He  then  speaks  of  some  of  the  disad- 
vantages which  it  has,  and  finally  concludes  as  follows :  "For  some  time 
to  come  there  will  be  a  certain  amount  of  advertising  advantage,  but 
as  soon  as  this  has  been  dissipated  through  the  fact  that  every  one  will 
be  prepared  to  administer  this  form  of  anesthesia,  its  drawbacks  must 
become  apparent  as  compared  with  its  advantages." 

[Dr.  Ochsner  thus  places  considerable  emphasis  on  the  advertising 
campaign  which  has  been  used  for  nitrous  oxide-oxygen.  We  have  had 
this  in  a  marked  degree  in  Columbus,  though  from  what  I  can  learn  no 
more  extreme  than  has  been  the  rule  in  other  cities.  We  have  had  ex- 
tensive write-ups  in  the  newspapers,  even  with  illustrations  of  the  appa- 
ratus, and  with  flowery  eulogies  of  the  comfort,  convenience,  and  abso- 
lute safety  of  this  new  anesthetic.  These  newspaper  "stories"  usually 
include  the  names  of  both  surgeon  and  anesthetist;  hence  both  are 
equally  interested  in  suppressing  all  information  as  to  disastrous  results.] 

[There  is,  however,  I  think,  another  vieiw  of  the  case  not  mentioned 
by  Dr.  Ochsner,  and  that  is,  the  financial  results  which  the  nitrous  oxide 
specialist  gets  from  this  anesthetic.  In  Columbus  the  usual  fee  for  an 
ordinary  anesthesia  by  ether  or  chloroform  is  five  dollars,  but  the  charge 
for  nitrous  oxide-oxygen  is  from  ten  to  twenty-five  dollars.  Possibly 
a  few  whififs  may  be  given  for  less  than  ten  dollars,  but  in  other  in- 
stances the  charge  exceeds  the  maximum  which  I  have  stated.  Of 
course,  it  is  well  kno-wn  that  gas  is  more  expensive  than  ether  or  chlo- 
roform, but  as  the  cost  of  the  gas  is  given  as  less  than  two  dollars  an 
hour  of  administration,  the  expense  in  individual  cases  amounts  to  very 
little  while  the  cash  returns  are  large.] 

[I  had  all  along  suspected  that  in  the  background  of  the  campaign 
for  this  new  anesthetic  there  was  a  mercenary  motive,  but  any  lingering 

11 


doubt  which  I  might  have  had  vanished  when  at  a  recent  meeting  of 
our  Academy  of  Medicine,  at./ which  the  subject  of  anesthetics  was  being 
discussed,  a  visiting  specialist  from  Cincinnati  stated  that  an  anesthetist 
could  not  make  a  living  if  he  limited  his  work  to  ether  and  chloroform.] 

[As  an  honest  proposition  it  would  seem  that  if  five  dollars  per  anes- 
thesia for  ether  and  chloroform  is  not  sufficient,  there  should  be  a  manly 
increase  in  charge  rather  than  that  the  anesthetist  should  resort  to  a 
more  unsatisfactory  and  more  dangerous  anesthetic  agent  in  order  that 
he  may  secure  a  larger  fee.  Such  an  attitude  is  contrary  to  all  the  tradi- 
tions of  our  profession,  and  when  once  known  to  the  public  can  only 
bring  anesthetists  and  the  profession  isto  disrepute.] 

In  Columbus  nitrous  oxide-oxygen  deaths  have  occurred  at  the  hands 
of  three  administrators,  all  of  whom  are  looked  upon  by  their  friends 
as  thoroughly  competent  specialists.  Deaths  have  occurred  to  each  in 
frequency  just  about  in  proportion  to  the  number  of  administrations 
for  major  operations.  Dr.  Rice  has  lost  the  largest  number,  but  has 
undoubtedly  had  more  administrations  in  major  work.  Dr.  Howell,  who 
has  made  a  personal  study  of  nitrous  oxide-oxygen  anesthesia,  and  has 
watched  many  such  administrations  at  Lakeside,  Cleveland,  and  who 
has  until  recently  used  nitrous  oxide-oxygen  almost  exclusively,  tells 
me  that  he  regards  Dr.  Rice  as  the  most  skillful  nitrous  oxide-oxygen 
anesthetist  in  the  State.  The  anesthetist  who  had  but  one  death  had 
given  this  anesthesia  in  about  fifty  cases. 

We  are  told  by  many  that  while  deaths  on  the  table  are  exceedingly  rare 
from  ether,  many  deaths  occur  later  from  pneumonia,  which  should  be 
charged  up  to  ether.  Those  who  make  these  statements  should  cer- 
tainly read  Rovsing  (p.  85),  who  considers  this  matter  briefly  but  very 
forcibly:  "It  is  astonishing,  moreover,  that  the  misconception  that  ether 
has  a  harmful  influence  on  the  pulmonary  passages  still  exists,  because 
in  reality  the  correctness  of  this  view  has  long  since  been  refuted,  both 
clinically  and  experimentally.  From  a  clinical  point  of  view  it  was 
Mikulicz's  report  in  1898,  which  drove  the  nail  home.  Mikulicz,  on  ac- 
count of  the  somewhat  frequent  occurrence  of  postoperative  pneumonia, 
had  deserted  ether  and  taken  up  chloroform,  in  the  belief  that  the  pneu- 
monia was  due  to  the  irritating  effect  of  the  ether.  To  his  surprise, 
however,  it  appeared  that  the  cases  of  chloroform  narcosis  were  fol- 
lowed by  a  still  greater  percentage  of  postoperative  pneumonia.  He, 
therefore,  decided  to  give  up  narcosis  by  inhalation  entirely,  and  there- 
after employed  local  anesthesia  in  all  operations,  even  the  major  ones. 
But,  to  his  yet  greater  surprise,  the  result  was  that  the  lung  compli- 
cations, far  from  decreasing,  increased  to  a  considerable  extent;  with 
114  laparotomies  he  had  no  less  than  twenty-seven  lung  complications. 

12 


Naturally,  this  experience  overthrew  the  old  conception  that  postoper- 
ative cases  of  pneumonia  were  'narcosis  pneumonia.'  One  curious  fact 
should  long  ago  have  aroused  the  surgeon's  suspicions ;  namely,  that 
almost  every  'narcosis  pneumonia'  manifested  itself  after  laparotomy, 
while  it  is  extremely  rare  to  find  pneumonia  following  operations  on  the 
extremities,  thorax,  and  head.  To  what  was  this  strange  occurrence 
due?  Surely,  in  the  main,  to  two  circumstances:  (1)  That  peritoneal 
infection  is  conveyed  to  the  lungs  partly  by  way  of  the  lymph  vessels 
and  venous  blood,  and  partly  by  embolism,  and  (2)  that  a  patient  with 
a  laparotomy  wound  dares  not  cough  or  breathe  freely,  inasmuch  as 
this  involves  pain  in  the  wound.  If,  therefore,  the  patient  is  already 
suffering  from  bronchitis,  or  if  an  infection  of  the  lungs  sets  in,  the 
development  of  pneumonia  is  greatly  favored  by  the  deficiency  in  ex- 
pectoration and  lung  ventilation. 

"It  has  been  proved  experimentally  with  animals — and  I  myself  have 
substantiated  the  fact  by  experiments — that  ether  does,  indeed,  occasion 
increased  salivation  in  the  salivary  glands  of  the  mouth,  but  that  the  air 
passages — larynx,  trachea,  and  bronchi — are  not  irritated  at  all,  even 
when  the  animals  are  killed  by  administering  ether  through  a  trache- 
otomy tube  until  they  are  dead.  Therefore,  the  only  way  in  which  ether 
narcosis  per  se  can  cause  pneumonia  is  by  aspiration  of  accumulated 
saliva  in  the  throat.  This,  however,  is  always  due  to  some  technical 
error  in  the  narcosis,  for  saliva  should  not  be  allowed  to  accumulate  in 
the  throat  to  any  extent.  ...  If,  therefore,  it  is  proved  that  the 
ether  fumes  do  not  in  any  way  irritate  the  main  air  passages,  one  should 
admit  that  the  other  assertion  must  also  be  wrong.  I  mean  the  asser- 
tion that  ether  is  contraindicted  in  patients  suffering  from  lung  disease: 
emphysema,  bronchitis,  bronchiectasis,  abscess  of  the  lung,  etc." 

I  have  had  ether  administered  in  very  many  thousands  of  cases ;  years 
ago  by  use  of  the  old-fashioned  cone,  then  the  Allis  inhaler,  and  now 
for  a  number  of  years  by  some  form  of  the  drop  method.  I  have  never 
had  a  death  on  the  table  from  its  administration.  I  cannot  recall  a 
single  death  from  postoperative  pneumonia.  I  have  had  two  or  perhaps 
three  deaths  from  suppression  of  the  urine.  It  is  possible,  perhaps  prob- 
able, that  this  suppression  was  the  result  of  the  action  of  the  ether  on 
the  kidneys,  and  yet  we  all  know  that  deaths  from  suppression  occur  in 
cases  in  which  no  anesthetic  whatever  has  been  given,  and  earlier  in 
this  paper  I  have  referred  to  one  death  in  which  suppression  of  the  urine 
followed  the  administration  of  nitrous  oxide-oxygen. 

Nitrous  oxide-oxygen  has  a  field  of  usefulness  to  which  it  should  be 
strictly  limited.  It  can  be  used  for  very  brief  operations,  as  it  has  been 
for  many  years  in  the  extraction  of  teeth.    It  is  also  probably  the  safest 

13 


anesthetic  to  use,  as  suggested  by  Ochsner,  in  cases  of  acute  pulmonary 
congestion,  or  of  acute  nephritis.  With  these  exceptions,  which  make 
its  field  a  very  limited  one,  nitrous  oxide-oxygen  should  be  looked  upon 
as  the  most  dangerous  anesthetic  that  can  be  used,  even  in  the  hands 
of  the  most  experienced. 

[Some  three  years  ago  I  asked  two  young  men  who  were  about  to 
make  a  pilgrimage  to  Cleveland,  to  the  shrine  of  Lakeside  Hospital, 
to  inquire,  not  of  the  surgeons  who  were  known  to  favor  this  anesthetic, 
but  of  the  young  doctors  who  are  always  found  hanging  about  such 
an  institution,  as  to  the  general  opinion  of  nitrous  oxide-oxygen.  Both 
came  back'  with  the  report  that  these  young  men  promptly  stated  that 
nitrous  oxide-oxygen  was  the  most  dangerous  anesthetic  that  could  be 
used.] 

REFERENCES. 

1.  Rovsing:     Abdominal   Surgery,  1914. 

2.  Gwathmey  :      Anesthesia,   19H. 

3.  Connell:     Art.     Anesthesia  in  Johnson's   Operative  Therapeusis. 

4.  Luke:  N.   Y.  Medical  Journal,  January  20,   1915. 

5.  Ochsner ;     Manual  of  Surgery,  1915. 

—  N.   Y.  Medical  Record,  July  29,  1916. 

NOTE. 

The  above  article  was  read  before  the  Tenth  District  Medical  So- 
ciety at  its  Chillicothe  meeting,  and  was  sent  for  publication  to  the 
editor  of  the  Journal  o£  the  American  Medical  Association.  It  was 
promptly  returned  with  certain  criticisms.  The  parts  objected  to, 
as  nearly  as  I  could  determine  them,  were  cut  out,  and  the  manu- 
script re-submitted,  but  only  to  be  again  promptly  rejected.  It  was 
then  sent  in  its  elided  form  to  the  editor  of  the  New  York  Medical 
Record,  who  promptly  published  it. 

At  least  two  other  articles  adverse  to  nitrous  oxide-oxygen  anes- 
thesia have  been  submitted  to  the  Journal  of  the  American  Medical 
Association,  only  to  be  rejected.  One  of  these,  by  a  prominent  ob- 
stetrician of  Kansas  City,  was  later  published  in  the  American  Jour- 
nal of  Obstetrics,  and  the  other,  by  a  New  York  anesthetist,  in  the 
Medical  Record.  Several  articles  lauding  this  anesthetic  have  ap- 
peared in  the  Association  Journal,  but  so  far  as  I  can  learn  none 
criticising  it  have  ever  been  published  by  it. 

The  average  member  of  the  A.  M.  A.  probably  thinks  that  its 
Journal  is  a  forum  for  the  discussion  of  all  subjects  involving  pro- 
fessional matters,  but  instead  it  seems  to  be  conducted  as  a  sort  of 
private  organ  of  the  editor,  who  admits  only  such  articles  as  fit  his 
Procrustean  bed. 

In  reprinting  the  paper  those  parts  which  were  cut  out  are  repro- 
duced in  [  ],  so  that  the  paper  as  it  now  appears  is  the  paper  as 
it  was  originally  read. 

J.  F.  B. 
14 


THE  DANGER  OF  NITROUS  OXIDE-OXYGEN. 

To  THE  Editor  of  the  Medical  Record  : 

Sir:  —  In  your  issue  of  January  13,  1917,  is  an  interesting  article 
by  Dr.  Seybold,  an  anesthetist  of  Denver,  Col.,  in  which  he  reports  some 
half  dozen  bad  cases  in  which  nitrous  oxide-oxygen  was  administered 
without  fatality.  That  ether  would  have  been  fatal  in  any  one  of  the 
cases  would  undoubtedly  be  questioned  by  expert  ether  anesthetists. 
He  also  reports  two  deaths  under  nitrous  oxide-oxygen.  Of  one  he  is 
unable  to  give  particulars,  but  gives  full  details  of  his  own.  Those  of 
us  who  are  familiar  with  Cabot's  occasional  strictures  on  ill  advised 
surgery,  as  they  appear  from  time  to  time  in  his  comments  on  autopsies 
as  issued  weekly  by  the  Massachusetts  General  Hospital,  can  readily 
imagine  the  causticity  of  his  remarks  on  the  inadvisability  of  operation 
in  the  case  reported.  Nevertheless,  it  is  an  open  question  whether  the 
patient  would  not  have  survived  the  immediate  operation  under  the 
stimulating  effect  of  ether  inhalations,  which  he  failed  to  do  under  the 
nitrous  oxide-oxygen. 

In  an  article  which  I  contributed  to  the  Medical  Record  in  its  issue 
of  July  29,  1916,  I  reported  a  list  of  fourteen  deaths,  in  practically  all 
of  which  there  could  be  no  question  as  to  the  direct  fatal  influence  of 
nitrous  oxide-oxygen.  I  also  reported  a  number  of  other  deaths  occur- 
ring in  different  cities.  Furthermore,  and  this  is  a  matter  of  prime 
importance,  I  reported  that  in  published  or  personal  communications 
several  surgeons  or  nitrous  oxide-oxygen  anesthetists  of  national  repu- 
tation had  admitted  knowledge  of  a  number  of  deaths,  namely.  Miller, 
18  deaths;  Rovsing,  13  deaths;  Teter,  26  deaths,  nine  of  which  occurred 
in  Cleveland ;  Gwathmey,  20  to  40  deaths.  Very  few  of  the  above  deaths 
have  been  reported. 

I  have  noted  with  interest  and  satisfaction  that  Bloodgood,  in  the  De- 
cember issue  of  Progressive  Medicine  (pages  23-5),  announces  that  at 
the  Johns  Hopkins,  where  nitrous  oxide-oxygen  was  used  so  enthusi- 
astically a  very  few  years  ago,  they  have  within  the  past  eighteen  months 
gradually  returned  to  ether.  He  particularly  condemns  nitrous  oxide- 
oxygen  in  cases  in  which  the  blood  pressure  is  high.  In  addition  to  the 
discontinuance  of  the  nitrous  oxide-oxygen  in  his  own  clinic  he  adds  (p. 
242)  "the  clinics  which  first  began  the  routine  employment  of  gas- 
oxygen  anesthesia  instead  of  ether  are  beginning  to  swing  back  to  ether." 

15 


In  the  Mayo  clinic,  as  stated  in  my  article,  after  some  1,400  adminis- 
trations of  nitrous  oxide-oxygen,  with  no  reported  fatality,  that  anes- 
thetic was  abandoned  in  favor  of  ether. 

I  think  the  profession  and  laity  should  unite  in  demanding  of  anes- 
thetists, who  know  of  these  unreported  deaths,  immediate  and  full  report 
of  their  mortality,  that  the  actual  status  of  this  anesthetic  agent  may  be 
positively  determined.  Possibly  some  such  communications  have  been 
sent  to  medical  journals,  but  have  been  denied  publication.  I  know  of 
three  articles  unfavorable  to  nitrous  oxide-oxygen  which  have  been  re- 
fused publication  by  the  Journal  of  the  American  Medical  Association, 
though  it  has  published  a  considerable  number  of  articles  highly  lauda- 
tory of  that  anesthetic. 

Columbus,  Ohio.  J.  F.  Baldwin,  M.  D. 

—  N.  Y.  Medical  Record,  March  3,  1917. 


16 


SHOCKLESS  OPERATIONS. 

The  clinical  picture  of  shock,  following  injury  or  operation,  is 
familar  to  every  experienced  physician.  Various  theories  have  been 
advanced  to  explain  the  phenomena  connected  with  this  condition,  but 
none  of  them  has  been  accepted  as  entirely  satisfactory.  The  latest 
theory  is  that  of  Crile,  based  upon  certain  findings  in  his  private  lab- 
oratory. Unfortunately,  however,  these  findings  have  not  been  cor- 
roborated by  workers  in  other  laboratories,  whose  reports,  on  the  con- 
trary, so  far  as  published,  have  been  antagonistic  to  his  theory. 

While  it  is  universally  conceded  that  excessive  hemorrhage  is  the 
most  common  cause  of  shock,  it  must  be  admitted  that  certain  trau- 
matisms may  produce  the  same  clinical  symptoms,*  but  just  how  these, 
symptoms  are  produced  is  a  question  which  has  not  been  answered. 
If  Crile's  theory  is  correct,  then  more  or  less  shock  should  be  found 
in  all  extensive  operations  in  which  no  precautions  are  taken  to  block 
by  injections  the  nerves  connecting  the  field  of  operation  with  the 
brain  centers.  If  shock  frequently  appeared  when  no  injections  were 
used,  and  did  not  appear  when  they  were  used,  the  problem  would  be 
greatly  simplified. 

The  promptness  and  unanimity  with  which  operators  who  have 
adopted  anoci-association  attribute  absence  of  shock  in  their  operations 
to  the  use  of  the  injections,  would  be  purely  amusing  did  it  not  present 
such  a  pitiful  illustration  of  illogical  thinking.  Crile's  theory  is  beauti- 
fully simple,  and,  presented  in  his  captivating  way,  it  naturally  leads 
superficial  thinkers  astray,  so  that  their  reasoning  assumes  the  post  hoc 
ergo  propter  hoc  circle,  while  a  more  logical  mind  might  regard  it  all 
as  purely  a  non  sequitur. 

A  rude  operator  who  accomplishes  his  end  largely  by  mere  brute 
force,  who  is  indififerent  as  to  hemorrhage,  and  careless  as  to  pro- 
tection of  his  field  of  operation,  will  doubtless  meet  with  much  shock; 
and  if  he  later  learns  gentler  methods,  is  more  cautious  as  to  hemo- 
stasis,  and  more  careful  in  protecting  the  operative  field,  he  will  find 
the  shock  disappear,  and  if  in  the  meantime  he  has  been  induced  to 
use  the  so-called  "anoci-association"  he  may  be  deluded  into  attributing 


*  "The  most  common  cause  of  so-called  surgical  shock  is  collapse  from  loss  of  blood,  and 
traumatfsm  of  important  structures  in  hasty  attempts  to  control  hemorrhage." — W.  T.  Mayo, 
"Jour.   A.   M.   A.,"   March  20,   1915. 


17 


all  his  improvement  to  the  latter  while  ignoring  the  former  essentials. 
Crile  is  a  fine  anatomist,  an  accomplished  surgeon,  and  a  skillful  opera- 
tor, and  I  suspect  that  in  his  modesty  he  has  mistaken  the  results  of 
his  own  skill  for  the  results  of  his  "anoci-association."  . 

While  fear  and  anxiety  on  the  part  of  the  patient  are  undesirable, 
it  is  very  doubtful  if  those  conditions  alone  will  produce  shock.  At 
least  out  of  an  experience  of  nearly  ten  thousand  abdominal  operations 
I  have  never  met  with  a  single  instance,  although  I  have  operated  on 
patients  who  were  almost  frantic  from  fear,  with  a  resulting  high  pulse 
rate,  and  even  an  elevation  of  temperature  which  could  be  explained 
by  nothing  in  the  physical  condition;  yet  after  the  operation  (an  hys- 
terectomy perhaps)  temperature  and  pulse  have  at  once  dropped  to 
normal,  and  the  patients  have  made  an  absolutely  smooth  convales- 
cence. Nevertheless,  the  experienced  surgeon  will  naturally  possess  a 
hopeful  mental  attitude,  and  will  impart  more  or  less  of  his  own  opti- 
mism to  his  patient.  In  that  way  he  will  change  her  attitude  of  fear 
to  one  of  hope  and  courage.  In  these  cases  the  administration  of 
scopolamin-morphin,  an  hour  before  the  giving  of  the  anesthetic,  is 
very  helpful,  and  many  patients,  although  really  awake  when  the  anes- 
thetic is  commenced,  have  no  recollection  of  it,  and  when  coming  out 
from  the  anesthesia  a  number  of  hours  later  can  hardly  be  convinced 
that  an  operation  has  been  performed. 

After  discussing  this  matter  with  a  colleague  in  December,  I  decided 
to  take  particular  notice  of  my  own  operative  cases  for  the  next  month 
or  two,  and  see  what,  if  any,  shock  occurred  from  operations  per  se. 
In  my  regular  routine  work  during  sixty  days  (January  1-March  1) 
I  performed  120  major  operations.  During  this  time  I  did  many  minor 
operations,  but  in  none  of  the  operations,  whether  major  or  minor,  did 
there  appear  ^any  suggestion  of  that  combination  of  symptoms  which 
we  call  shock. 

The  anesthetic  used  in  all  the  cases  was  the  drop-ether,  preceded  (ex- 
cept in  children)  by  a  hypodermic  injection  of  1/6  grain  morphin 
and  1-100  grain  scopolamin.  This  is  a  combination  I  have  used  for 
many  years,  and  in  thousands  of  cases,  and  with  only  the  most  gratify- 
ing   results. 

My  patients  are  all  private  patients,  and  during  convalescence  are 
looked  after  daily  by  myself.  They  are  seen  during  the  few  days  fol- 
lowing operation  not  less  than  twice  a  day,  oftener  if  necessary,  and 
then  once  a  day  during  the  later  convalescence. 

Operations  are  performed  as  rapidly  as  is  consistent  with  thorough- 
ness, and  the  patients  usually  sleep  quietly  for  an  hour  or  more  after 
returning  to  their  rooms.     Post-operative  nausea  occurs  in  some  cases, 

18 


but  in  others  there  is  no  complaint  whatever.  The  same  is  true  of 
gas  pains,  though  fewer  escape  the  latter  than  escape  the  nausea.  Care 
is  taken  in  closing  the  incisions,  that  the  parts  are  brought  into  appo- 
sition, but  not  so  tightly  as  to  interfere  with  either  the  nerves  or 
blood-vessels  in  the  line  of  suture.  Too  ^reat  tension  is,  I  think, 
responsible  for  much  local  post-operative  pain.  As  a  result,  in  a  num- 
ber of  cases  patients  who  have  had  abdominal  operations  performed 
without  their  knowledge  have  suspected  nothing  of  it  until  the  first 
dressing  at  the  end  of  the  week.  Patients  usually  greet  me  on  the 
morning  after  operation  with  a  pleasant  smile,  and  except  that  they 
may  have  had  some  stomach  disturbance  express  themselves  as  feeling 
quite  well;  are,  indeed,  generally  pleasantly  disappointed  by  the  absence 
of  disagreeable  sensations. 

That  the  injection  of  urea  and  quinine  into  the  field  of  operation  so 
obtunds  sensibility  as  to  relieve  some  of  the  post-operative  pain  about 
the  wound  is  undoubtedly  true;  but  if  care  is  taken  in  adjusting  and 
closing  the  wound,  bringing  the  parts  into  snug  but  not  too  tight  ap- 
position, patients  will  have  little  cause  for  complaint.  It  is  notorious 
that  post-operative  wound  infection  is  much  more  common  in  cases  in 
which  the  quinine  and  urea  have  been  used  than  in  those  in  which 
the  usual  closure  is  made,  and  many  surgeons  who  have  used  this  com- 
bination for  purposes  of  local  anesthesia  have  complained  of  infection 
and  even  sloughing  of  the  edges  of  the  incision.  Whether  the  increased 
liability  to  infection  is  due  to  the  drugs  themselves,  or  to  trophic 
changes  due  to  interference  with  innervation,  has  probably  never  been 
positively  determined;  but  the  fact  remains,  and  most  patients  would 
prefer  to  have  the  slight  increase  of  his  discomfort  from  the  non-use  of 
the  quinine  and  urea  than  to  suffer  from  the  greater  and  more  pro- 
longed  disturbance    connected    with   the   post-operative    infection. 

At  the  present  time  we  are  hearing  very  much  about  "twilight  sleep" 
in  connection  with  obstetrical  practice,  and  those  who  use  it  claim 
that,  owing  to  the  absence  of  pain  and  anxiety,  the  patients  are  re- 
markably free  from  the  depressing  effects  of  the  confinement,  and  are 
ready  to  be  up  and  around,  if  permitted,  within  forty-eight  or  even 
within  twenty-four  hours.  If  the  theory  of  brain-cell  exhaustion  from 
unfelt  pain  is  correct,  these  patients  should  all  show  more  or  less  signs 
of  shock,  but  the  advocates  of  the  method  claim  that  the  reverse  is  true. 

A  number  of  years  ago  a  head  nurse,  who  came  to  the  Grant  Hos- 
pital from  an  institution  in  the  East,  repeatedly  expressed  her  surprise 
at  the  absence  of  shock  which  she  found  in  our  operative  cases.  In 
talking  with  her  I  found  that  the  surgeons  she  had  previously  served 
had  been  in  the  habit  of  taking  an  hour  or  two  to  make  a  twenty- 

19 


minute  operation;  they  had  been  rather  indifferent  to  hemorrhage  and 
to  protecting  the  field  of  operation,  and  they  had  not  employed  the 
delicacy  of  touch  in  intra-abdominal  work  which  due  respect  for  that 
field  of  operation  demands ;  hence  the  presence  of  shock  there  and  its 
absence  here. 

There  is  undoubtedly  a  large  number  of  surgeons  in  the  country 
who  could  from  their  records  more  than  duplicate  my  report  of  shock- 
less  cases.  I  have  talked  with  many  such  surgeons,  and  they  tell  me 
that  they  do  not  have  shock  in  their  work,  except  under  conditions 
which  have  been  previously  mentioned.  Shockless  operations  are  the 
rule,  the  others  the  rare  exception. 

Within  the  last  few  weeks  I  have  known  of  two  deaths  from  shock, 
one  from  an  exploratory  incision  with  considerable  manipulation  of  the 
parts,  the  other  from  an  abdominal  hysterectomy  for  fibroid.  In  both 
the  operator,  who  is  a  firm  believer  in  anoci-association,  had  used  his 
local  injections  and  had  administered  nitrous  oxide-oxygen  instead  of 
ether.    The  contrast  was  painful,  but  the  pain  was  not  mine. 

In  my  abdominal  operations  the  appendix  is  practically  always  re- 
moved as  a  routine  procedure,  even  if  it  presents  no  gross  evidence 
of  disease.  In  the  appended  report  the  appendix  was  so  removed,  though 
it  does  not  appear  in  the  printed  record. 

I  am  a  firm  believer  in  the  importance  of  decayed  teeth  in  the  pro- 
duction of  many  constitutional  disturbances,  and  consequently  in  all 
cases  my  anesthetist  at  the  completion  of  the  operation  examines  the 
teeth,  and  if  old  roots  or  rotten  teeth  are  discovered  which  are  past 
saving  by  the  dentist,  they  are  at  once  extracted;  and  many  a  patient 
has  really  shown  more  gratitude  for  the  removal  of  these  old  teeth 
than  for  the  removal  of  the  pathology  for  which  the  operation  was 
undertaken. 

In  operating  for  uterine  cancer,  unless  there  are  positive  contra- 
indications, I  perform  the  usual  radical  Wertheim  operation,  with  pre- 
liminary ligation  of  both  internal  iliacs  as  recommended  by  Cobb.  The 
ligation  of  these  vessels  renders  the  operation  almost  bloodless,  and 
this  hemostasis  obviates  shock. 

In  operating  for  cancer  of  the  breast,  the  usual  "dinner-plate"  opera- 
tion of  Rodman  is  ordinarily  pursued,  with  a  thorough  dissection  of 
the  axilla,  but  saving  enough  of  the  pectoralis  major  to  protect  the 
axillary  vessels,  as  recommended  by  Murphy.  In  many  of  these  cases 
it  is  necessary  to  make  transverse  incisions,  with  undermining  of  the 
opposite  breast,  so  as  to  bring  it  over  to  cover  the  raw  surface. 

In  cases  of  gangrenous  appendicitis,  temporary  drainage  is  usually 
advisable.     This  is  done  by  making  a  stab  incision  in  close  proximity 

20 


-=       " 


O 


_bfi  a 


5  2c 

o    o    rt 

J-i      ;_,     • — I 
Q-i      (L)      rt 

^   >>  "S 
-c  j:  J5 


C 


(L) 


rt     03     5 

.2  .S  ^ 
'So  "So  __. 

>     >     9. 


(U    tn 
C     " 


5  <u 

■^  5 

o  o 

W3 


re     C3     b- 


X    c 

.     in 


P-i    < 


'^      U,      U      <U    J^ 


a,  ^  -. 

D     3     "U 

m  m  Pi 


<   CO 


.  ^ 
c   "J   !^ 

^.   o    o 


c     _  _ 

lU      o  (J 

o<  C  C 

<  o  u 


C     to 


O     p3 


J3 
O 


rt  "5  .5  a:   c 


Q      ^       ^       .jH 


2        E 


o  ^    o    <u    cu 

4-1      <U      C      C 

o    c    aJ  •-    ^- 


^    o    H 


rt 


'So 


E  '^ 
o  „ 

'     03 


C 


5    >> 


to 

'in  «J 

O  S 

S  ^ 

O  P 


c 

>. 

, 

, . 

r^ 

ns 

n 

C 

c 

'-i-1 

-t-;    -O     _     -M 


qj      C      (U     Qj 


.5    '-' 


*-i     rr     ^     *-H     »-(   ,i-i 
<U     O     (U     OJ     g    ■!-> 


•c    F    rt 


p    o    o 


^  S 


i!  t: "« 


,C     in 


?     >. 


bfl 

E      £ 


(D       C3 


«  _  ^    0,0 


o  „ 


a,  ^ 


<  < 


■U     C     rt    --; 


Oh      3       O 

<    CO   fc 


3 


<  U  s     <  CO  P  g 


c^  ;^  fe  fe  fc  :^  ;§  fe  fe  fo  :^  ^  ix;  tt;  ^  ^  ^L;  h  Ph'  ^  ^  h  ^  ^  ^  ^  ^  1^'  ^  ph'  ^  § 


:5  o  h4  h4  fe  <  w  pq  ^  m  m  0  u  >  u  Q  ffi  <  q  ^  w  fc-  K  ^  ^  q  d  o  q  ^  J  2 
h5  w  U  <"  U  ffi  c/i  w  h-:>  w  pi  U  U  Pi"  M  <  fe  ^  K  u  K  N  w  ffi  !i:  d  U  w  ;§  (^'  pd  u 


c5'HNfO-<*l»r5tOl>OOCE>OiHNCOrtl«O^I>      00 
!_,  ■iHrHi-liHiHTH'~'T-ti-< 


21 


>1 

a, 
a 


S     3 


^  ^ 


Q  -6 


(U     J:i     O 


H    9< 


a  > 


Q    9   S    ^   o 


Q  "3 

£  o 
o 

^  § 

tn 

.       ^  (V) 


O 
(J 


J3     u 


rt  .S  .^  c 


rt     o 


c   S 


< 


<  w 


<    C/} 


1    o 

'^^ 
s  g 

a.  o< 
CO  < 


TO        (U 


P-. 


s  :h 


3 
O 


rt 


<u 


Vh  o 

.s 

«<  a 

.-  o 


'O     o 


^    o 


^   -G  si 

n   <u  t! 

^     dJ  o 

<;  PL,  o 

-d    >>  I-. 

a.  -c  "u 

(LI       O  ^ 

c  ^  p 

"Cog 


bo 

.5    p 
£    5 


_-  •-I  1^ 

to     ^      (U 
OJ       CO     --H 

'COS 

rt   (In   r« 

>      u 


^     3 


< 


bfl 

03  .5 

>-     3 


>. 

>i 

s 

s 

s 

a 

o 

o 

o 

, 

CJ 

u 

<]> 

<ij 

U) 

•T3 

S 

>> 

CJ 

(1) 

OS 
.§1 


(L>      <U      O    ^     t^ 


Oh  a. 

Oh     & 

<    < 


<  U 


^6 


X 

n1 

to 

> 

G 

3 

hn 

O 

CJ 

C3 

> 

3 

CJ 

,Tl 

n, 

V-. 

Oi 

■-s 

3 

< 

CO 

H 

o 


03      o3 

CO 

3     03 

cd     oj 


o 


>   o 


c    c 

OS     o3 


S     G 


°    o    y    o 


<U      (J 
be  ;" 

u  "a 

o3     o3 


c5    4^    »-    ^ 


3     E     a  ^ 


to 
>>     . 

•^  gj 
•— <   "" 

c  c 
•p  rt 

S  li 

O   rt 


O     rt     o.    >,  ^   ^ 

Q  U  <  Ph    ^     " 


■a  Id  -75 
^  ^  ^  oj- 

<  <  <;u 


C/2  [i;  fe   tLJ    fe  [x;  ^'    I-Lh'   fe    fe   fe  fc"  S   S   ^   Ph'  ^   fe   fe   Plh'  fe'  tiM*  fe   h   (Jh"   fc   §   S   [i;  fo   [lifc 


ffi 


X 


X 


:5  ffi  K  ^  m  ^ 
^S  >:  fe  ^  J  Q  w 


ffi  <■  w  w.      M  w  w  K4  J  J  H      J       •  ^'  §■  ^'  § 

K  ffi   h4  U  W  ^  ^-  c^  ^  ^  ^  ^-  p:j  ^  ^-  ^.  ^.  ^  ^-  ^.  ^  ^. 


^  CO  ffi  u  :§'  f^'i^. 


^.  i-i  --<•'--.  ^^.  ►^  ?*  ^  I  u  i-^  r^  '=-:  1-1  p^  h-i  rj  ^.  LO  1^.  u  <5  [^1=^. 
U  HJWgcoU>:h^Wh-Afe^OfeH-:,h-:>KUH^Ui-^H^!l|U 


(MrO^*»OCO?^00050 


22 


o 

u 


2 


S  •« 


o 

J2 

>> 

U 

> 

s 

o 

>, 

<u 

<u 

g 
o 

13 

/— . 

(J 

« 

u 

0) 

c 

a 

O 

ll 

(L) 

« 

S 

(U 

g 

a; 

y 

.2 

'S 

u 

ID 

a! 

D< 

c 

"5 

u 

s^O 

, 

3 

G 

"rt 

>. 

J3 

ll 

.S 

'5) 

o 

<u 
^3 

'3 

be 

s 

o 

"o 

OJ     o 

rt 

<u 

<Ll 

cJ 

OJ     u 

> 

1-1 

+^ 

S 
o 

O.    rt 

CI* 

o 

rt 

"bJD 

o. 

u 

a  > 

3 

J3 

> 

o. 

rt 

<  o 

CO 

o 

s  < 

CO 

O     P 


■^        B 


^-   S 


.2  H 


CO   b 


03    _0 


t;    r-    o 


o    3  ^ 


hr 

u 

n 

!-H 

O 

o. 

'■n 

rrt 

If) 

m 

>> 

>^ 

.   -s 

^ 

B 

o    f1    >>   ^ 


X  S  -2 

.«      TO      (1 
>      Oh     O 


rt     O 


c    ^ 
"3  '*-" 


<  < 


I       TO 

CO  P:i 


»<  o 
o  ^ 


'O     ui    ^ 


>>'?, 


1)    c 

>    S 
.      CI, 


o  .a 

U      TO 

S  2 

<  CO  ffi 


o   g 


.  *?  c 

S     n!  lu 

•=  -^  -a 

^      C  <U 

<^  'a  S 

C    g  ii 

■3  ^  ■^ 

K^    <  CO 


Pi 


,5    o.  o 


S    ^    f= 


O     0<    CO 

CO  (/I  O 


-u'     ^    _J     ^     nn     tn     rv>     ^     10     to"     02     m     ^-^     O     05     CO     ■*'     »C     •^'     Cvi     1-5     O     W     »n     02     Oi     O     tJh     O     ■*     ^     W 

^'  fe  fe'  fe  fe  :§'  ;^'  fe"  fe  fc  ;^'  ph"  ^  ^  ^  ^  fc'  fe  fe  fc  ^  ^  ^  ^  ^  p^h'  s  ^  ^  ^  ^  ^ 


^  .  ^  ^  ^  .  .  ^-  s 
w  ^  >  c/i  ^'  ^  ;^  ^.  pci  ^ 


^  .  ph"  (^'  S  •       ^'  ^-  ^!  ^-  "^^       J  '^• 

^.  ^  d;  Ph"  P^  &^'  ^'  c4  ^'  ^-  ^-  pi  P^  H  S"  d  K  ^  in  c/i  H  tc 

^  :^  fc  CO  w  H-i  ffi  H^  <  ^  ^  fc  :?  a  fc  t/i  d  pi  <  N  ^  cA. 


sssss"s§g^^^'s:^s'^'?2?isss^sss;2S^g8S§ssss 


23 


cu 


o 


O 


G  .  E 

rt  >,  O 

"  S  ^ 

u  Q  <u 


u  in 


rt 


rt 


c  p. 


^    5= 
^     OS 

A      Oh 


lU    •—      t-i 

..   o 
<u  o 


QJ       <U       U       Ih 


^     ^  s 


o 
u 


— '  l-l 


°.5 


u    g  .S 


a 

2  -^  ,bfl  5  -s 


C     P 


u     03 


la 

en 

"So  -CJ 

Stectom 
hystere 
pyosalp 
stectom 
n  of  t 
nal  pan 

.s 

3 

rt  g 

>     S 

1        (U 

5?  13  ^   5"  "^   S 

.ii    o 

^  .ii  3  ii   ^   o 

•o  -o 

&c    O 

O  X)     5     O     tn   'O 

a> 

ni  ^ 

3    ^ 

j5     rt     O   ^     oj  ^ 

«   < 

C/2   C/! 

O  P4  Q  U  P4  < 

1 — 1 

"     o    >» 

Co  H 

"  -a 


en  T3 


0<     (U 

'^  .S    c 
■5)13  -S 

rt    CO    cj 

'T  <u  -^ 
rt  "^  S 
£  -^     oj 

a,  3  o, 
3  o  a 
uo  Q  <; 


OS     S 
>     c3 

o    bo 


o   c 

> 


6 


tn 


<U 


"     r-     ^ 


^.2     cS 


<U      rt 


..5  ■" 

o   5  i? 

■S  ^  o 

O     r<  '^ 

u  v5  u 


S  5P  - 


C       CT5 


CS    o 


^    o 


<  Q  < 


be 


fe 


ttifefetefefofeSfepiHfefepiHteSfofe^fegfefefe 


fe 


c/) 


S  K  Q  < 


CO 


> 


in  O  '^.  <^. 


H  f4  ^-     .  H     .  >•     .  ^     .  ^.  .>. 

H  H  ^.  ^'  U  t^  W  ^  5  ^  W  ^  ^  ^'  ^  S  ^ 


N 


.-.  ^  &h'  ^  u  p:i  ^  :^'  w  <  u  H^  h^  :^  w  §  ^  (J  w  h4  u  1^  h4  Q  h4  :^  w 


O    iH    N    CO    Tt<    m     to 

0000000 


24 


to  tlie  anterior-superior  spine,  and  passing  from  within  out  a  cigarette 
drain,  together  with  the  catgut  ligatures  which  have  been  used  and 
have  been  left  long.  By  a  little  traction  on  these  ligatures  the  cecum 
can  usually  be  so  adjusted  as  to  lie  in  contact  with  the  wick,  so  that 
there  will  be  no  post-operative  ileus  from  adhesions  involving  the  small 
bowel.  The  main  incision  is  closed  thoroughly  so  as  to  obviate,  if 
possible,  post-operative  hernia. 

The  case  of  macroglossia  (No.  31)  is  reported  as  a  major  operation, 
because  of  the  special  feebleness  of  the  infant,  which,  owing  to .  the 
large  size  of  the  tongue  and  its  protrusion,  had  become  so  weakened 
by  lack  of  food  as  to  render  amputation  of  the  tongue  particularly 
hazardous. 

The  hip-joint  amputation  (No.  87)  was  in  a  slender  and  anemic 
woman,  whose  leg  was  nearly  as  large  as  her  body.  I  have  performed 
in  all  about  ten  hip-joint  amputations,  using  the  Wyeth  method,  with- 
out shock  and  without  mortality. 

Deaths. — The  deaths  reported  are  all  that  took  place  following  these 
operations,  and  no  patients  were  hurried  out  of  the  hospital  to  im- 
prove the  statistics.  Statistics  are  entirely  unreliable  unless  we  know 
just  how  they  are  obtained.  Some  well-known  surgeons  exclude  from 
their  reports  a  considerable  number  of  cases  who  have  died  after  op- 
erations, but  in  which  death  was  not  due  to  the  operation  itself.  Such 
methods  of  securing  statistics  are  very  unreliable,  since  the  personal 
equation  is  so  uncertain,  and  the  results  may  be  quite  fantastic. 

Number  24.  This  patient  was  first  operated  upon  under  Number  23. 
She  was  then  found  to  have  uterine  hyperplasia,  with  a  mass  of  pelvic 
adhesions,  requiring  a  supravaginal  pan-hysterectomy.  In  addition  she 
was  suffering  from  pronounced  intestinal  obstruction  which  was  found 
due  to  seven  strictures  of  the  small  bowel,  these  strictures  having 
resulted  from  tuberculous  ulcerations.  At  the  first  operation  the  three 
tightest  strictures  were  cared  for  by  an  intestinal  anastomosis  above 
and  below  the  strictures.  The  condition  of  the  patient  was  then  such 
as  to  render  it  unsafe  to  treat  the  four  remaining  strictures,  which 
were  not  quite  so  tight.  She  made  an  excellent  recovery,  and  three 
weeks  later  the  other  four  strictures  were  relieved  by  lateral  anas- 
tomoses. She  went  through  this  operation  nicely,  but  at  one  point, 
because  of  the  condition  of  the  intestinal  wall,  a  cigarette  drain  was 
inserted.  Here,  as  feared,  an  intestinal  fistula  formed,  which  after 
discharging  freely  for  a  few  days  closed  down,  until  at  the  time  of 
her  death  some  weeks  later  there  was  little  discharge.  She  died  of 
exhaustion  from  tuberculosis  some  three  weeks  after  the  second 
operation, 

25 


Number  58.  This  patient  had  had  serious  stomach  trouble  for  ten 
years,  worse  of  late,  with  a  strong  suspicion  of  malignancy  implanted 
on  gastric  ulcer.  The  ulcer  was  found  in  the  posterior  wall  of  the 
pylorus,  with  much  exudate,  thoroughly  organized.  A  pylorectomy  was 
done  in  the  usual  way,  but  with  great  difficulty  on  account  of  the  ex- 
tensive adhesions  and  exudate.  The  man  did  well  after  the  operation 
for  forty-eight  hours,  then  became  suddenly  restless,  with  poor  pulse, 
air-hunger,  absence  of  second  heart  sound,  and  the  usual  symptoms  of 
heart  clot.     He  died  in  a  few  hours. 

Number  74.  This  patient  was  in  desperate  condition  at  the  time  of 
the  operation,  which  was  for  the  removal  of  an  ovarian  tumor  with 
twisted  pedicle,  which  was  found  to  be  papillomatous,  with  extensive 
metastases  involving  the  upper  abdomen.  She  went  through  the  op- 
eration very  satisfactorily,  and  for  several  days  bid  fair  to  make  an 
excellent  operative  recovery,  but  died  suddenly  on  the  fifth  day.  Im- 
mediate cause  of  death  not  found  at  necropsy. 

Number  83.  This  was  a  case  of  chronic  metritis  with  extensive 
adhesions.  While  apparently  convalescing  well,  she  died  suddenly  on 
the  seventh  day,  probably  from  pulmonary  embolism. 

Number  100.  This  patient  was  operated  upon  for  umbilical  hernia 
and  gall-stones.  She  was  very  fleshy,  weighing  about  300  pounds,  and 
in  closing  the  umbilical  hernia  a  lipectomy  was  done  for  her  relief. 
She  went  through  the  operation  easily,  but  died  suddenly,  as  though 
from  embolism,  on  the  second  day. 

Number  101.  This  patient  was  operated  upon  for  advanced  cancer 
of  the  uterus,  the  usual  radical  operation  with  ligation  of  the  internal 
iliacs.  She  did  well  for  a  week,  but  then  commenced  failing  and  died 
of  exhaustion  about  three  weeks  after  her  operation.  The  disease  Avas 
found  to  be  more  extensive  at  the  time  of  her  operation  than  had  been 
anticipated,  and  should  have  been  regarded  as  inoperable. 

Number  103.  This  was  a  difficult  cholecystectomy  for  gall-stones, 
with  extensive  exudate  and  a  cancerous  development  involving  the 
deeper  structures,  and  metastasis  to  the  liver.  She  was  greatly  re- 
lieved by  the  operation  with  its  drainage  of  the  bile  ducts,  but  died  of 
exhaustion  some  weeks  later. 


Conclusions. 
1.     Crile's    laboratory    findings,    showing    exhausted    brain    cells,    on 
which  he  bases  his  theory  of  shock,  have  not  been  confirmed  by  inde- 
pendent   laboratory    workers,    and    such    confirmation    is    clearly    very 

desirable. 

26 


2.  Operative  shock,  from  a  practical  standpoint,  is  the  result  of 
hemorrhage,  or  of  undue  and  usually  unnecessary  traumatism  in  the 
field  of  operation. 

3.  Prolonged  operations,  by  the  long  exposure  of  the  field  of  op- 
eration and  the  prolonged  anesthesia,  materially  increase  the  liability 
to  shock,  so  that  a  moderate  hemorrhage,  which  would  not  produce 
any  ill-effects  in  a  short  operation,  may  result  in  marked  shock. 

4.  Any  surgeon  who  operates  rapidly,  who  guards  against  unneces- 
sary hemorrhage,  and  who  avoids  brutality  in  handling  tissues,  will 
have  shockless  operations. — Amer.  Jour,   of  Surgery,   Aug.,    1915. 


27 


THE  TECHNIC  OF  ABDOMINAL  HYSTERECTOMY.* 

The  technic  of  hysterectomy  has  been  a  matter  of  steady  evolution. 
The  principles  of  the  operation  have  been  long  established,  but  there  are 
little  details  which  have  not  been  brought  out  and  which  may  add  mate- 
rially to  the  satisfaction  of  the  operation  and  to  its  safety.  Most  oper- 
ators  have   felt  that  an   abdominal  panhysterectomy   was   considerably 


I^iG.   1. — Glass  tube  with  bulb  for  injecting  iodine  into  the  uterus.      (%  size.) 

more  difficult,  and  had  a  materially  higher  mortality,  than  the  subtotal 
or  supravaginal  operation.  By  the  technic  which  I  have  finally  devel- 
oped, as  the  result  of  2018  operations  for  the  removal  of  the  uterus,  I 
feel  that  the  complete  removal  is  almost  as  simple,  and  fully  as  safe, 


Fig.  2. 

as  the  less  complete  procedure,  while  it  entirely  removes  the  possibility 
of  malignant  changes  in  the  retained  cervix,  and  more  or  less  morbidity 
from  inflammatory  or  degenerative  changes  which  may  be  present,  or 
which  may  occur,  in  the  part  that  is  left  behind.  The  steps  of  the  oper- 
ation are  as  follows : 

1.  Thoroughly  wash  out  the  vagina  with  soap  and  hot  water.  This 
is  done  when  the  patient  is  under  the  anesthetic,  and  advantage  should 
be  taken  of  the  opportunity  to  make  a  more  thorough  examination  of 
the  pelvic  organs  than  was,  perhaps,  possible  without  anasthesia.  Seize 
the  cervix  with  a  volsella,  and  fill  the  uterus  with  full  strength  tincture 


•  Read    before    the    Twenty-ninth    Annual    Meeting    of    the    American    Association    of    Ob- 
stetricians   and    Gynecologists    at    Indianapolis,    Ind.,    September,    1916. 

28 


of  iodine  by  means  of  an  appliance,  made  for  this  purpose,  shaped  some- 
thing like  a  large  medicine  dropper  (Fig.l).  The  iodine  should  be 
applied  as  well  to  the  outside  of  the  cervix.  The  cervix,  which  had 
been  pulled  down  somewhat  to  steady  it,  is  now  pushed  up,  and  by 
means  of  a  feeding  cup  (Fig.  2)  an  ounce  or  two  of  tincture  of  iodine, 
reduced  to  one-fourth  its  normal  strength,  is  poured  into  the  vagina. 
By  a  sort  of  pumping  motion  with  the  volsella  this  iodine  is  spread  over 
the  walls  of  the  entire  vagina.  The  volsella  is  then  removed,  and  by 
means  of  gauze  the  excess  of  iodine  is  wiped  out  of  the  vagina. 

2.     Open  the  abdomen  by  the  usual  incision,  place  the  patient  in  the 
Trendelenburg  position,  and  wall  off  the  intestines  by  gauze  sponges. 


Fig.    3. — Cutting    and    ligating    right    infundibulo-pelvic    ligament. 


The  uterus  is  seized  by  a  tumor  clamp  and  thoroughly  pulled  up,  so 
as  to  bring  the  cervix  as  close  as  possible  to  the  abdominal  wall.  A 
hysterectomy  clamp  (Fig.  3)  is  placed  on  the  infundibulo-pelvic  liga- 
ment, just  outside  the  right  ovary  (I  always  stand  on  the  right  side  of 
the  patient)  and  a  second  clamp  is  placed  at  the  horn  of  the  uterus  so 
as  to  catch  the  uterine  artery  at  that  point.  An  incision  is  made  inside 
the  first  clamp,  the  scissors  turning  at  a  right  angle  at  the  end  of  the 
clamp  so  as  to  cut  back,  for  a  ligature,  the  tissues  between  the  point  of 
the  clamp  and  the  round  ligament.  (If  an  ovary  is  to  be  saved  the  first 
clamp  is  applied  so  as  to  catch  the  ovarian  ligament  and  the  Fallopian 

29 


tube  close  to  the  uterus.    Later  the  tube  is  detached  from  the  ovary  and 
a  ligature  applied.) 

3.  Cut  the  round  ligament  close  to  the  uterus,  and  dissect  the  parts 
down  to  a  point  corresponding  to  the  internal  os.  This  exposes  the 
uterine  artery  which  is  caught  with  a  hemostat  (Fig.  4)  and  cut.  The 
same  maneuver  is  executed  on  the  opposite  side. 

4.  Ligatures  are  applied  to  the  ovarian  and  uterine  arteries,  and  the 
clamps  removed.  Four  ligatures  have  controlled  hemorrhage.  There 
is  no  hemorrhage  whatever  from  the  cut  end  of  the  round  ligament — 
notwithstanding  that  all  of  our  text-books  show  the  round  ligaments  care- 
fully ligated  as  though  hemorrhage  would  otherwise  take  place. 

5.  The  uterus  is  pulled  forward,  and  with  scissors  the  peritoneum 


Fig.    4. — Ligating    uterine    artery.      No   bleeding    from    round    ligament. 


is  incised  transversely  just  above  the  point  of  attachment  of  the  utero- 
sacral  ligaments  (Fig.  5),  and  dissected  down  for  half  or  three-quarters 
of  an  inch,  being  careful  not  to  button-hole  it.  This  peritoneal  flap  is 
then  caught  with  a  hemostat  so  as  to  hold  it  out  of  the  way. 

6.  The  uterus  is  pulled  backward,  and  the  peritoneum  from  in  front 
of  the  cervix  is  carefully  dissected  down  with  scissors,  carrying  with  it 
the  bladder.     The  vagina  is  freed  by  snips  with  the  scissors  and  gauze 

30 


wiping  on  the  sides  as  well  as  in  front.     Here  occasionally  a  little  artery 
will  need  to  be  caught  and  tied. 

7.  The  vagina  having  been  well  exposed,  and  being  directly  under 
the  eye,  is  caught  with  a  hysterectomy  clamp  placed  transversely  just 
below  its  attachment  to  the  cervix  (Fig.  6),  and  with  scissors  the  vagina 
is  opened  by  a  transverse  incision  above  this  clamp.  Air  enters  the 
vagina  and  it  at  once  balloons.  Another  hysterectomy  clamp  then  catches 
the  anterior  wall  of  the  vagina  at  right  angles  to  the  cut  which  has  been 
made,  and  the  clamp  previously  applied  is  removed  (Fig.  7).     Gauze  is 


Fig.    5. — Peritoneum   incised   above   uterosacral    lisaments. 

then  pushed  into  the  opening  so  as  to  absorb  any  iodine  which  may  have 
been  expressed  from  the  uterus  during  the  manipulations. 

8.  The  finger  is  introduced  through  the  opening  into  the  vagina,  or 
a  strong  hook,  and  by  means  of  traction  and  scissors  the  vagina  is  separ- 
ated on  the  side  next  the  operator  to  a  point  in  the  posterior  wall  directly 
opposite  the  clamp  which  has  caught  the  anterior  wall.  The  assistant 
applies  a  second  clamp  at  this  point,  and  then  the  incision  is  completed 
around  the  cervix  and  the  uterus  removed.  This  leaves  the  vagina 
gaping  wide  open,  but  held  up  firmly  by  the  clamps  applied  to  the  front 

31 


and  back  (Fig.  8).    If  there  is  any  bleeding  from  the  edge  of  the  vagina 
the  bleeding  vessels  can  be  readily  caught  and  ligated. 

9.  A  curved  needle,  threaded  with  chromicized  catgut  (I  usually 
use  No.  1  double),  is  passed  from  within  the  vagina  out  on  one  side, 
through  the  round  ligament  which  has  been  caught  at  its  end  by  an 
assistant  and  pulled  directly  inward,  and  returned  from  without  in, 
entering  the  vagina  a  quarter  of  an  inch  from  its  first  point  of  pas- 
sage. The  end  of  the  round  ligament  is  pushed  down  into  the  vagina 
by  the  assistant,  the  ligature  tied,  and  the  hemostat  removed  (Fig.9). 
The   same  procedure   is   executed  on   the   opposite   side.      This   leaves 


Fig.   6. — Uterus  pulled  backward  and  peritoneum   with  bladder  dissected  down  over  the  vagina. 


the  vagina  held  up  by  the  hysterectomy  clamps   front  and  back,  and 
by  the  round  ligaments  on  each  side. 

10.  A  chromicized  catgut  suture  is  passed  in  and  out  in  the  sub- 
mucous tissue  around  the  end  of  the  vagina,  not  penetrating  the 
mucous  membrane,  and  under  each  round  ligament  (Fig.  10).  The 
assistant  removes  the  clamps  and  this  purse  string  suture  is  tied,  the 
ends  of  the  round  ligaments  and  the  edges  of  the  vagina  being  pushed 
in  by  the  assistant  by  means  of  an  inverter  (Fig.  11).     This  thoroughly 


Fig.    7. — Opening  vagina   in   front. 


Fig.   8. — Final   detachment  of  uterus   from  vagina. 

33 


closes  the  end  of  the  vagina,  and  brings  the  round  ligaments,  and  in 
part  the  broad  ligaments,  into  close  apposition  in  the  midline  (Fig.  12). 

11.  With  iodine  catgut  the  peritoneum  in  front  and  back  is  brought 
together  by  continuous  suture,  commencing  above  the  stump  of  the 
ovarian  vessels  on  one  side,  continuing  across  and  up  to  a  correspond- 
ing point  on  the  opposite  side.  By  catching  the  peritoneum  by  a  sort 
of  Lembert  suture  the  raw  edges  are  all  inverted  and  the  floor  of  the  pelvis 
is  left  perfectly  smooth   (Fig.  13).     The  appendix  is  then  removed,  the 


Fig.    9. — Implanting    round   ligaments   into   the   vagina.      Note   knot   on   the   inside. 


parts  examined  for  adhesions,  kinks,  gall-stones,  etc.,  and  the  incision 
closed  in  the  usual  manner. 

12.  The  gauze  which  was  pushed  into  the  vagina  from  above  is 
now  removed  from  below,  the  vagina  wiped  out,  and  a  piece  of  iodo- 
form gauze  passed  in  and  pressed  up  to  the  vault  so  as  to  absorb  any 
oozing,  and  to  furnish  support  to  the  vault  in  case  of  postoperative 
vomiting.  This  gauze  is  removed  at  the  end  of  two  or  three  days, 
and  the  parts  then  kept  clean  as  usual. 


The  main  advantages  of  this  technic  are : 

1.  Quite  satisfactory  sterilization  is  made  by  the  iodine  of  the 
uterine  cavity  and  of  the  walls  of  the  vagina. 

2.  The  parts  from  start  to  finish  are  held  up  so  as  to  be  thor- 
oughly under  the  eye,  and  within  easy  reach  for  controlling 
hemorrhage. 

3.  The  smooth  closure  of  the  pelvic  floor  leaves  no  point  for  adhe- 
sions, hence  no  postoperative  ileus. 

4.  The  work  is  done  rapidly  because  of  the  complete  exposure  of 
the  parts  and  their  being  within  easy  reach. 


J 


Fis.    10.^  Both   round   ligaments   implanted  and  pursestring  inserted   passing   under    each    round 
ligament  so  as  to  bring  in   the  broad  ligament. 

5.  The  support  of  the  vault  of  the  vagina  is  most  satisfactory  and 
complete. 

In  cases  in  which  owing  to  extensive  adhesions  the  peritonum  cannot 
be  whipped  over,  the  sigmoid  should  be  mobilized  and  attached  to  the 


Fig.    11, 

peritoneum  in  front  so  as  to  cover  the  raw  surface.  In  cases  in  which 
pus  is  present,  or  oozing  is  feared,  the  round  ligaments  are  implanted 
in  the  vagina  as  previously  described,  but  the  posterior  wall  is  then 
split  downward  for  a  distance,  and  the  true  pelvis  lightly  packed  with 

35 


a  washed  piece  of  iodoform  gauze  of  ample  size,  one  end  of  which 
has  been  pushed  down  into  the  vagina  so  that  it  can  be  removed  from 
below;  over  this  gauze  the  sigmoid  is  mobilized  as  described  above. 
The  gauze  is  removed  in  about  one  week. 


Vv 


Fig.    12. — Purse    string   tightened   bringing   the   parts   into    close    apposition. 

In  cancer  cases  the  ligation  of  the  internal  iliacs,  exposure  and  pro- 
tection of  the  ureters,  and  other  necessary  steps  of  the  radical  operation 
are  carried  out  in  the  usual  way,  but  when  possible  with  implantation 
of  the  ligaments  into  the  shortened  vagina  so  as  to  prevent  its  prolapse. 

The  above  technic  I  have  used  for  several  years,  and  have  found  it 
to  be  ideal,  both  in  immediate  execution  and  in  end-results. — From 
Amer.  Jour  Ohstet.  and  Dis.  Children,  vol.  Ixxv,  No.  2,  1917. 


Fig.    13.-^Anterior    and    posterior    peritoneum    brought    together    from    side    to    side    leaving 

absolutely   no   raw   surface. 

36 


TREATMENT  OF  PUERPERAL  THROMBOPHLEBITIS.* 

While  the  average  mortality  of  puerperal  pyemia  is  ordinarily  re- 
garded as  between  67  per  cent  and  75  per  cent,  it  is  probable  that  the 
mortality  of  pyemia  due  to  infected  thrombophlebitis,  in  which  the  veins 
of  the  broad  ligaments,  the  internal  iliac,  or  the  ovarian  are  involved, 
is  100  per  cent;  at  least,  I  have  not  been  able  to  find  any  cases  of  re- 
covery without  operation  on  record  in  which  such  a  lesion  was  demon- 
strated by  subsequent  operation  or  history. 

The  classical  symptoms  of  pyemia  from  infected  thrombophlebitis 
are  repeated  chills,  with  corresponding  wide  fluctuations  of  tempera- 
ture, with  direct  evidence  to  the  touch  of  involvement  of  the  veins  of 
the  broad  ligaments  on  one  or  both  sides.  It  is  possible,  as  in  the  case 
reported  by  Jellett,  that  there  may  be  no  evidence  of  involvement  of  the 
broad  ligament,  but  such  a  condition  is  a  rare  exception. 

Treatment  of  these  conditions  by  vaccines  and  serums  is  quite  uni- 
formly conceded  to  be  futile,  and  expectant  treatment,  if  the  diagnosis 
is  correct,  means  a  mortality  of  100  per  cent. 

In  1909,  J.  Whitridge  Williams,  of  Baltimore,  contributed  an  exhaust- 
ive article  on  this  subject,  in  which  he  made  a  study  of  fifty-six  operated 
cases  (Amer.  Jour.  Obstet.  vol.  lix.  No.  5).  Five  of  these  cases  were 
his  own,  with  one  death.  Excluding  from  the  entire  number  of  cases 
certain  ones  in  which  there  was  an  error  in  diagnosis,  or  technic,  he 
concludes  that  operative  mortality,  when  the  thrombus  is  limited  to  the 
ovarian  veins,  should  not  exceed  10  per  cent,  provided  the  operation  is 
performed  early;  when  other  vessels  are  involved,  the  mortality  he  places 
at  25  per  cent.  The  operation,  he  says,  should  be  undertaken  as  soon 
as  the  diagnosis  can  be  made,  "which  is  assured  whenever  a  worm-like 
mass  can  be  palpated  at  the  outer  portion  of  the  broad  ligament  in  pa- 
tients suffering  from  chills  and  a  hectic  temperature." 

The  transperitoneal  route  he  greatly  prefers  to  any  form  of  extraperi- 
toneal operation.  His  technic  is  ligation  of  the  infected  veins  beyond 
the  point  of  extension  of  the  thrombus. 

Hiram  N.  Vineberg  (Amer.  Jour.  Obstet.,  July,  1913)  reports  a  case 
in  which  he  excised  not  only  the  entire  right  ovarian  vein  up  to  the  vena 
cava,  but  removed  also  the  uterus.     His  patient  recovered  promptly. 

In  August,  1913,  Jellett,  Master  of  the  Rotunda  Hospital  of  Dublin 
(Surgery,  Gynecology  and  Obstetrics),  presented  quite  an  exhaustive 
monograph  on  this  subject,  in  which  without  hesitation  he  earnestly 
recommends  operative  treatment.    He  reports  five  cases  with  two  deaths. 

Most  of  the  operators  recommend  excision  of  the  veins  following  liga- 
ture, but  Williams  in  his  monograph  states  that  this  treatment  is  rarely 
necessary,  but  that  ligation  is  sufficient. 

In  my  own  experience  I.  have  operated  in  four  of  these  cases  with 

*  Read  before  the  American  Association  of  Obstetricians  and  Gynecologists  at  Buffalo, 
Sept.    15-17,   1914. 

37 


one  death.  The  details  of  the  cases  are  without  interest,  as  they  present 
no  unusual  features.  One  followed  an  induced  abortion,  the  others  full- 
term  labor.  In  all  the  characteristic  symptoms  were  present.  I  report 
the  cases  because  the  operative  technic  which  I  adopted  varied  from 
that  recommended  by  the  surgeons  who  had  previously  reported.  In 
all  of  my  cases  the  thickened  vein  was  readily  identified,  and  in  two  of 
them,  in  addition  to  the  ovarian,  some  of  the  branches  of  the  internal 
iliac  were  involved.  All  of  the  patients  were  in  desperate  condition,  and 
\t  seemed  wise  to  complete  the  operation  as  rapidly  as  possible.  Ac- 
cordingly a  hysterectomy  was  made,  after  sterilizing  the  vagina  and 
endometrium  with  iodine,  and  the  vagina  left  widely  opened.  The 
affected  veins  were  then  exposed  by  separating  the  peritoneum,  and  cut 
across  with  free  escape  of  rotten  blood  clot.  Care  was  taken  to  manipu- 
late the  veins  as  little  as  possible  so  as  to  avoid  pushing  the  clot  toward 
the  vena  cava.  This  was  especially  true  after  my  first  fatality.  No 
attempt  at  ligation  of  the  veins  was  made,  but  ihe  pelvis  was  filled  with 
an  iodoform  gauze  fluff  pushed  down  from  above  into  the  vagina,  and 
over  this  the  sigmoid  flexure  of  the  colon  was  stitched  around  the  pelvis 
so  as  to  completely  occlude  the  peritoneal  cavity.  As  the  patients  were 
all  young  an  ovary  was  saved  in  each  instance.  In  three  of  the  cases 
prompt  recovery  ensued.  In  the  fourth  there  had  evidently  been  a  dis- 
turbance of  the  clot,  and  death  occurred  suddenly. 

In  all  four  cases  the  uteri  submitted  to  the  pathologist  were  found  by 
him  to  contain  multiple  abscesses,  showing  that  the  removal  had  been 
wise.  By  thus  detaching  the  uterus,  with  ligation  merely  of  the  arteries, 
the  veins  of  the  broad  ligaments  are  left  free  to  drain  into  the  gauze 
fluff,  and  thus  out  of  the  vagina,  so  that  a  beginning  thrombus  in  any 
one  of  them  would  most  likely  prove  harmless.  By  making  no  effort 
to  excise  or  even  ligate  the  veins,  a  minimum  of  manipulation  and  trau- 
matism results,  with  correspondingly  diminished  risk  of  breaking  oif  a 
portion  of  the  clot  to  drift  into  the  vena  cava. 

As  the  infection  reaches  the  veins  through  the  sinuses  in  the  uterine 
wall,  it  is  evident  that  in  a  large  proportion  of  cases  the  uterine  wall 
itself  is  the  seat  of  abscesses,  as  proved  to  be  true  in  all  my  cases,  and 
the  removal  of  the  uterus  not  only  gets  rid  of  a  source  of  continued 
infection,  but  also  gives  absolutely  free  drainage  of  all  the  veins  that 
can  possibly  be  directly  at  fault.  These  veins  are  usually  without  valves, 
and  with  a  free  opening  at  the  bottom  where  the  infected  clot  is  break- 
ing down,  the  contents  would  naturally  extrude  in  that  direction,  instead 
of  extending  upward,  as  must  necessarily  be  the  case  when  no  direct 
down  drainage  is  secured.    The  fatal  case  I  here  report  more  at  length : 

Mrs.  E.,  aged  twenty-six.  Married  eighteen  months.  One  early 
miscarriage  about  a  year  before.  Was  delivered  by  her  physician,  April 
22,  1914,  with  forceps,  the  instrument  being  applied  with  the  head  on 
the  perineum,  and  without  laceration.  Thirty-six  hours  later  she  had  a 
chill  with  a  temperature  of  105°.  She  had  daily  chills  from  that  time 
until  the  26th,  when  I  saw  her  in  consultation.  Blood  count,  23,000 
leukocytes,  90.6  per  cent  polynuclears.  Vaginal  examination  showed 
some  laceration  of  the  cervix  on  the  right  side.  In  the  left  broad  liga- 
ment, however,  was  found  the  t3rpical  condition  showing  infection  at  that 

88 


point.  Right  broad  ligament  entirely  free.  Vaginal  discharges  odorless. 
I  advised  expectant  treatment  of  the  case  for  a  few  days,  but  with  oper- 
ation later  if  the  conditions  did  not  improve.  April  27  the  patient's 
condition  was  pretty  fair  all  day.  No  chill,  but  continued  high  temper- 
ature. On  the  28th  and  29th  no  chills,  but  general  condition  not  so 
good.  Temperature  104°.  Some  tenderness  now  in  the  right  broad 
ligament  as  well  as  the  left,  but  could  make  out  no  distinct  mass  on  that 
side.     Operation  advised. 

Operation. — Median  incision.  The  veins  in  both  broad  ligaments 
were  found  involved,  the  infection  extending  on  the  left  side  into  the 
ovarian  and  also  into  branches  of  the  internal  iliac.  A  pan-hysterectomy 
(except  the  ovaries)  made  in  the  usual  way,  with  wide  drainage  of  both 
broad  ligaments,  the  posterior  vaginal  wall  being  split  for  the  passage 
of  an  ample  gauze  fluff,  over  which  the  sigmoid  was  attached  all  around 
to  the  peritoneum. 

Examination  of  the  uterus  showed  the  entire  placental  area  to  be 
infected,  while  the  inner  surface  of  the  entire  cervix  was  sloughing. 
Minute  abscesses  in  the  walls  of  the  uterus  on  both  sides. 

For  forty-eight  hours  the  patient  materially  improved,  except  that  her 
pulse  and  temperature  failed  to  subside  as  much  as  had  been  hoped. 
She  reported  herself  as  feeling  fine.  On  the  morning  of  May  1  she 
seemed  a  little  better,  and  when  seen  about  six  o'clock  that  evening  had 
apparently  held  her  own  nicely  all  day.  I  was  called  out  of  the  city  at 
that  time,  and  when  I  returned  at  10:30  p.  m.  found  her  dying,  with 
every  evidence  of  plugging  of  the  pulmonary  arteries.  Death  was  at- 
tributed to'  a  breaking  loose  of  a  pelvic  clot. — From  Amer.  Jour.  Ohstet. 
avd  Dis.  of  Children,  vol.  Ixxi,  No.  2,  1915. 


39 


DERMOIDS  OF  THE  KIDNEY 

Works  on  diseases  of  the  kidney  quite  uniformly  state  that  only  two 
cases  of  dermoid  of  the  kidney  are  on  record,  and  with  unanimity  they 
refer  to  the  celebrated  case  of  Sir  James  Paget^  and  to  the  case  reported 
by  Professor  HaeckeP  in  1902.  Investigation,  however,  shows  that  a 
few  other  cases  are  to  be  found  in  the  literature.  Paget's  case  was  one 
of  dermoid  tumor  of  the  kidney  in  the  sheep.  It  seems  strange  that  this 
error  went  so  long  without  being  discovered,  but  it  was  finally  pointed 
out  in  1913,  by  W.  R.  Williams.^  The  discovery  was  easily  made,  as  the 
specimen  in  the  museum  of  the  Royal  College  of  Surgeons  is  described* 
as  follows : 

"3558-A.  A  large  tough-walled  cyst,  probably  dermoid,  which  was 
found  in  the  place  of  one  of  the  kidneys  of  a  sheep,  and  contained  a  mass 
of  wool  rolled  up  with  fluid  oil  and  fatty  matter.  The  cyst  is  inverted ; 
its  walls  are  from  one  to  two  lines  in  thickness ;  its  inner  surface  is 
rough  and  covered  with  portions  of  fatty  substance,  and  part  of  the 
wool  is  fixed  in  it.  A  long  cylindrical  tubular  process  is  continued  from 
the  main  cyst,  and  is  similarly  filled.  The  cyst  was  found  in  the  middle 
of  the  mass  of  fat  in  which  it  was  expected  that  the  kidney  lay.  No 
trace  of  kidney  appeared.  The  sheep  was  healthy  and  very  fat,  and  had 
a  good  fleece.    The  kidney  on  the  other  side  was  very  large." 

Case  1.  Haeckel's  case,  referred  to  above,  was  reported  in  full  by  his 
assistant,  Wedemann,  in  his  inaugural  dissertation.^  Female,  aged  58. 
Had  noticed  some  sort  of  swelling  in  the  right  side  for  several  years, 
but  only  for  a  few.  months  had  it  made  itself  prominent,  with  increased 
pain.  A  distinct  tumor.  No  urinary  trouble.  Menopause  at  37.  A 
hard  tumor  about  the  size  of  a  child's  head  in  the  ileocaecal  region, 
smooth  and  globular;  very  movable,  but  it  appeared  to  be  fixed  near  the 
anterior  superior  spine.  No  involvement  of  lumbar  region.  No  con- 
nection with  the  liver  or  genital  organs.  Operation,  November  25th, 
1901.  Incision  at  the  outer  border  of  the  right  rectus.  Tumor  easily 
removed,  with  prompt  recovery  of  the  patient.  The  tumor  was  cystic, 
its  surface  nodular  in  places,  filled  with  a  pultaceous  yellow  substance, 
traversed  with  bundles  of  hair. 

Case  2.  (Reported  by  W.  S.  Goldsmith.*)  The  patient  was  a  male, 
aged  20.  Had  had  evidence  of  trouble  with  one  kidney  since  two  years 
of  age.  Frequent  attacks  of  "colic."  The  tumor  had  been  recognized 
for  two  years.  Hsematuria  and  great  pain  were  pronounced  features. 
The  diagnosis  was  that  of  floating  kidney  with  twisted  pedicle.  Kidney 
removed  through  a  lumbar  incision.  Prompt  recovery.  Examination 
of  the  tumor  showed  kidney  remains  to  be  present,  but  the  main  mass 
was  made  up  of  a  cyst  containing  a  large  quantity  of  reddish,  mealy 
material  matted'  together  by  hair. 

Case  3.     (Reported  by  E.  W.  Walker.')     Girl,  aged  11  years.     Had 

40 


been  subject  to  attacks  of  so-called  "colic"  for  several  years.  The  at- 
tacks would  last  several  days,  and  were  attended  by  nausea,  vomiting, 
constipation,  tympanites,  and  irritable  bladder.  Pain  located  in  the  left 
lumbar  region,  and  tumor  noticed  -for  about  one  year  in  this  region. 
No  positive  diagnosis  made.  Exploratory  laparotomy,  July  15,  1895. 
Median  incision  four  inches  in  length.  The  tumor  was  found  to  be  the 
size  of  a  large  orange.  Had  a  long,  slender,  twisted  pedicle,  and  had 
contracted  light  intestinal  adhesions.  Removal  very  simple.  Prompt 
recovery.  Examination  of  the  tumor  showed  that  it  was  4>4  inches 
long,  2^  inches  wide,  and  1%  inches  thick.  Two-thirds  of  this  was 
taken  up  by  a  cyst.  There  seemed  to  be  three  dermoid  cysts,  one  of 
which  was  filled  with  fatty  material  and  fine  hair. 

Case  4.  (Reported  by  Schlegtendal,  B.,  and  Madelung.^  Male,  aged 
22.  Had  had  a  swelling  in  the  right  side  of  the  abdomen  as  long  as 
he  could  remember,  but  this  gave  no  trouble  until  six  months  before. 
The  tumor  was  in  the  right  upper  abdomen,  was  quite  extensive,  and 
apparently  connected  with  the  liver.  Diagnosis:  Echinococcus  of  liver. 
At  the  operation  two  incisions  were  made,  and  the  cyst  opened  and  at- 
tached to  the  skin  for  drainage.  About  a  bucketful  of  clear  yellow 
fluid  was  withdrawn,  but  this  contained  neither  hydatid  vesicles  nor 
booklets.  Patient  improved  for  a  few  weeks,  but  then  got  worse,  and 
died  some  months  later.  At  the  autopsy  the  liver  occupied  the  greater 
extent  of  the  abdomen.  Marked  amyloid  degeneration.  Spleen  much 
enlarged  and  adherent.  In  the  place  of  the  right  kidney  was  a  long 
tumor,  a  portion  of  which  extended  to  the  abdominal  wall,  where  a  fistula 
persisted.  The  greater  part  of  the  tumor  was  of  stony  hardness,  so  that 
it  had  to  be  cut  with  a  saw.  Cystic  spaces  were  present,  filled  with  a 
whitish,  smeary  mass  consisting  of  fine  fat-cells,  crystals  of  cholesterin, 
and  epidermis.  Renal  parenchyma  could  be  made  out  at  various  parts, 
and  epidermal  tissue  was  scattered  throughout  the  calcified  strata. 

Case  5.  (Reported  by  Enrico  Boni^)  Female,  aged  45.  Had  had 
symptoms  dating  back  about  15  years.  Swelling  noticed  for  ten  years 
in  the  right  side  of  the  abdomen.  Globular  tumor  present,  extending 
from  costal  arch  along  the  median  line  to  the  crest  of  the  ilium.  Not 
moved  by  inspiration.  Indistinctly  lobular.  Not  connected  with  the 
liver.  Diagnosis:  Hydronephrosis  probably  due  to  calculus.  Oper- 
ation, May  16,  1904.  Incision  at  border  of  right  rectus.  Tumor  re- 
nioved  as  usual,  with  a  large  gauze  drain  left  in  the  wound.  Patient 
died  four  days  later.  The  tumor,  the  size  of  an  adult  head,  contained 
five  intercommunicating  cysts,  filled  with  yellowish  green  turbid  fluid, 
and  detritus.  The  tumor  showed  typical  structure  of  skin,  with  sebac- 
eous sweat  _  glands,  hair  follicles,  and  hair  scattered  throughout  the 
several  sections. 

[A.  G.  Rider^  published  a  report  of  a  case  of  alleged  dermoid  cyst  of 

1  Surgical    Pathology,    London,    1853. 

2  Berl.   klin.    Wchnschr.,    1903,    xxxix,    964. 

3  Lancet,   Lond.,   i,    561. 

4  Descriptive    Catalogue    Pathological    Specimens    in   the    Museum    of   the    Royal    College    of 
Surgeons   of  England,    London,    1885,   iv,    18. 

5  Jena,    1902. 

6  Tr.,   Southern   Surg.   &   Gynec.   Ass.,   1908,   xxi,   95. 
7Tr.   Am.    Surg.   Ass.,   1897,   xv,   591. 

8  Arch.    f.    klin.    Chir.,    1887,    xxxvi,    304. 

41 


the  kidney  with  maHgnant  degeneration.  In  the  report  of  the  autopsy, 
however,  it  is  impossible  to  find  anything  pointing  to  a  dermoid,  and  the 
tissue  sent  to  the  Qinical  Research  Society  was  reported  as  a  columnar- 
celled  carcinoma.  The  tumor  was  removed  by  operation,  but  the  wound 
gave  way  with  prolapse  of  the  bowel,  and  death  of  the  patient.] 

Author's  Case.  Miss  M.  H.,  Degraff,  Ohio.  Physician,  Dr.  J.  H. 
Wolfe.  April  30,  1912.  Age  16.  Patient  was  seen  rather  hurriedly 
at  the  office  of  her  physician.  Appetite  fair,  bowels  regular,  kidneys 
normal,  menstruation  regular  and  normal.  The  mother  stated  that  her 
daughter  had  had  an  abdominal  tumor  ever  since  she  was  a  year  or  two 
old.  When  first  discovered  it  was  about  the  size  of  a  hen's  egg.  Had 
grown  with  the  growth  of  the  child,  but  of  late  had  been  growing  more 
rapidly.  The  patient  was  a  hearty  looking  schoolgirl.  She  presented 
a  tumor  about  the  size  of  a  cocoanut  in  the  right  side  of  the  abdomen. 
This  could  be  pushed  freely  in  all  directions.  Because  of  her  youth  made 
no  vaginal  examination,  but  from  the  mobility  of  the  tumor,  and  the 
history  of  its  long  existence,  made  a  presumptive  diagnosis  of  an  ovarian 
dermoid,  though  the  tumor  was  rather  large  for  a  growth  of  that  char- 
acter.   Its  prompt  removal  was  advised. 

I  saw  her  next  June  7,  1914,  and  examined  her  without  removing  her 
clothing.  The  tumor  was  about  as  before  except  somewhat  larger,  but 
still  quite  movable.    Urged  operation. 

Operation,  August  4,  1914,  Grant  Hospital,  Dr.  Wolfe  being  present. 
Examination  under  the  anesthetic  showed  that  the  tumor  was  not  of 
pelvic  origin.  Its  range  of  motion  seemed  to  indicate  that  it  was  of  the 
kidney  and  not  of  the  ovary.  It  was  hard  in  general,  but  irregularly  so, 
feeling  somewhat  like  a  hydrocephalic  head.  Made  an  incision  directly 
over  the  tumor  which  was  found  to  be  retroperitoneal  and  to  involve 
the  kidney.  A  transperitoneal  nephrectomy  was  made  without  diflficulty. 
Pelvis  organs  normal.  Appendix  removed.  To  provide  for  any  possible 
oozing  from  the  large  surface  which  was  exposed,  a  cigarette  drain  was 
passed  through  a  stab  incision  to  be  removed  in  a  few  hours.  The  colon 
was  then  carefully  replaced,  and  the  incision  closed  without  other  drain- 
age.    Patient  made  an  ideal  recovery. 

Examination  of  the  tumor  before  its  removal  showed  that  it  involved 
the  lower  half  of  the  kidney.  The  other  half  projected  from  the  tumor 
and  was  apparently  normal.  Studied  the  specimen  for  a  few  moments 
to  see  if  this  much  of  the  kidney  could  be  saved,  but  finally  decided 
against  it,  and  the  whole  organ  was  removed  and  turned  over  to  the 
pathologist.  His  report  showed  that  it  was  a  dermoid  of  the  kidney 
involving  the  lower  half.  The  walls  of  the  tumor  consisted  largely  of 
bony  plates,  while  the  interior  had  many  cavities  containing  different 
colored  fluids,  filled  with  cholesterin  crystals.  No  hair. — Surg.  Gxn.  and 
Obstet.,  Feb.,  1915. 


1  Osp.    magg.,    Milano,    1906,    i,    386. 

2  Lancet,    Lond.,    1906,    ii,    1589. 


42 


SPLENECTOMY    FOR    PERNICIOUS    ANEMIA;    APPARENT 
RECOVERY;   DEATH. 

So  much  has  been  written  of  late  in  regard  to  the  treatment  of  per- 
nicious anemia  by  splenectomy,  that  it  seems  important  that  every  case, 
whether  successful  or  the  reverse,  should  be  placed  on  record;  hence 
the  following  report: 

Miss  E.  S.,  aged  34,  patient  of  Dr.  J.  M.  Thomas,  Columbus,  Ohio, 
was  operated  upon  by  me  April  22,  1914,  for  pernicious  anemia.  The 
diagnosis  had  been  established  by  the  progress  of  the  disease  and  re- 
peated blood  examinations.  The  spleen  was  materially  enlarged.  The 
operation  was  made  in  the  usual  way,  occupied  but  a  few  minutes  of 
time,  and  the  patient's  operative  recovery  was  absolutely  smooth.  Her 
blood  examination  four  days  before  her  operation  showed  hemoglobin. 
30  per  cent;  reds,  1,616,000;  color  index,  1;  leucocytes,  5,400;  poly- 
nuclears,  65  per  cent.  Six  days  after  her  operation  the  hemoglobin 
was  22  per  cent;  red  cells,  1,632,000;  color  index,  1;  leucocytes, 
12,000 ;  polynuclears,  64  per  cent ;  small  lymphocytes,  30  per  cent ; 
large  lymphocytes,  5  per  cent ;  eosinophiles,  1  per  cent.  June  14,  hemo- 
globlin,  30  per  cent;  reds,  1,208,000;  color  index,  1.7;  leucocytes. 
18,000;  polynuclears,  83.6  per  cent;  small  lymphocytes,  12  per  cent: 
large  lymphocytes,  4.4  per  cent.  From  this  time  on  her  improvement 
was  very  rapid,  and  on  June  23  her  blood  count  showed  hemoglobin. 
68  per  cent;  red  cells,  3,319,000;  color  index,  1;  leucocytes,  6,400; 
polynuclears,  69  per  cent;  small  lymphocytes,  25  per  cent;  large  4  per 
cent;  eosinophiles,  2  per  cent.  At  this  time  the  patient  left  the  city 
to  visit  friends.  She  returned  in  July,  and  her  physician  reported  that 
on  her  return  he  found  that  she  was  in  bad  shape;  had  gone  all  to 
pieces.  The  disease  made  rapid  progress  and  she  died  July  29.  A 
specimen  of  her  blood  was  obtainel  a  few  hours  before  her  death, 
and  while  she  was  comatose.  This  showed  hemoglobin,  12  per  cent; 
red  cells,  720,000;  color  index,  1.4;  leucocytes,  37,000;  polynuclears, 
87  per  cent;  small  lymphocytes,  9.2  per  cent;  large  3.4  per  cent; 
eosinophiles,  0.4  per  cent. 

Any  surgeon  who  is  contemplating  splenectomy  for  pernicious 
anemia  should  read  the  article  by  Moffet  on  the  subject  of  this  form 
of  anemia  as  it  appears  in  the  American  Journal  of  the  Medical 
Sciences  of  December,   1914.— N.  Y.  Med.  Record,   Feb.  6,   1915. 


43 


CESAREAN  SECTION  FOR  UNUSUAL  INDICATION. 

Mrs.  E.  W.  H.,  aged  twenty-seven;  married  three  years.  Never 
pregnant.     Physician,   Dr.  Ranchous,  Columbus,  O. 

Patient  was  brought  into  the  hospital  Tuesday,  December  30,  1913. 
She  had  been  in  labor  at  full  term  since  the  previous  Friday.  She  had 
had  many  pains,  but  they  had  ceased  on  Monday  morning.  They  re- 
commenced, however,  in  the  afternoon,  and  all  through  the  night  had 
been  severe  about  every  five  minutes.  No  progress  had  been  made, 
however,  and  for  that  reason  I  saw  her  in  consultation. 

Examination  showed  patient  to  be  quite  plump.  Very  little  relaxa- 
tion of  the  vagina.  The  os  was  about  the  size  of  a  silver  dollar.  The 
breech  was  presenting,  but  had  not  descended.  The  head  was  under 
the  ribs  on  the  left  side,  and  everything  indicated  that  the  child  was 
unusually  large,  and  alive  and  vigorous.  Pelvic  measurements  normal. 
Mother's  general  condition  fair,  but  she  was  getting  tired  out. 

It  was  quite  evident  that  there  was  a  decided  disproportion  between 
the  child  and  the  pelvis,  this  disproportion  being  due  largely  to  the 
pad  of  fat.  To  deliver  under  the  circumstances  would  mean  almost 
certainly  a  dead  baby,  and  more  or  less  extensive  laceration  of  the 
maternal  passages.  For  those  reasons  I  advised  Cesarean  section.  The 
advice  was  accepted,  and  the  operation  carried  out  in  the  usual  way, 
making  the  high  operation.  The  child's  head  was  presenting  and  was 
delivered,  owing  to  its  large  size,  with  considerable  difficulty.  The  rest 
of  the  body  readily  followed.  The  operation  was  completed  in  the 
usual  manner. 

After  opening  the  abdomen,  the  omentum  was  iound  covering  the 
uterus  like  a  remarkably  thin  veil.  It  was  adherent  clear  across  at  the 
brim  of  the  pelvis,  the  adhesions  being  the  most  marked  on  the  right 
side.  This  omentum  was  pushed  over  to  the  left  before  incising  the 
uterus.  After  closing  the  uterus,  examined  again,  but  found  the  ad- 
hesions so  firm  that  it  seemed  unwise  to  attempt  to  separate  them  to 
find  the  appendix,  which  had  perhaps  been  responsible  for  the 
adhesions 

The  child  was  readily  resuscitated,  and  both  mother  and  child  left 
the  hospital  in  fine  shape. 

Breech  presentation  is  certainly  a  very  unusual  indication  for  Cesar- 
ean section,  and  yet  that  it  may  be  so  is  clearly  shown,  I  think,  by  the 
case  reported.  If  craniotomy  on  a  living,  viable  child  is  unjustifiable, 
except  under  most  unusual  circumstances,  then  certainly  delivery  by  the 
breech,  under  the  circumstances  in  which  my  patient  was  found,  would 
be  equally  unjustifiable,  since  the  death  of  the  child  would  be  almost  as 
certain  in  the  one  case  as  in  the  other. — Cin.  Lancet-Clinic,  Sept.  5,  1914. 


44 


FOUR  CASES  OF  "ACUTE  ABDOMEN"— FOUR  AUTOPSIES 
—FOUR  SURPRISES. 

1.  Mrs.  L.  B.,  aged  forty-seven  years.  Physician,  Dr.  D.  L.  Moore. 
Seen  at  Grant  Hospital  March  17,  1914.  Had  been  taken  suddenly 
at  4  p.  m.,  on  March  16,  with  severe  pain  in  region  of  the  gall-bladder 
and  liver,  the  pain  running  into  the  right  shoulder.  Had  had  slight  at- 
tacks of  trouble  at  this  point  at  intervals  for  the  last  year,  but  had  never 
vomited  with  any  of  them.  Had  been  vomiting  persistently  since  this 
attack  came  on.  Morphine  had  been  given  to  control  the  pain,  which 
the  daughter  described  as  "awful."  Had  never  had  typhoid  fever. 
No  jaundice,  but  the  urine  was  dark  in  color  the  day  before.  Had 
some  chilly  sensations  at  the  beginning  of  the  attack,  followed  by 
sweats.  Was  somewhat  stupid  from  the  morphine  when  she  was 
brought  in.  Examination  showed  the  patient  to  be  very  fleshy.  Pulse 
hard  and  somewhat  increased  in  frequency.  Could  find  no  tenderness 
at  any  point,  but  Dr.  Moore  and  the  daughter  both  stated  that  the 
tenderness  before  the  opiate  had  been  excessive.  The  abdomen  was 
quite  distended.  Blood  count  by  Dr.  Shilling  showed  33,000  leukocytes, 
95.6  per  cent  polynuclears.  Diagnosis  absolutely  uncertain,  but  with 
the  blood  count,  the  collapse  and  the  patient's  facial  expression,  which 
was  bad,  advised  against  any  attempt  at  operation.  When  patient 
was  out  from  under  the  morphine  I  examined  her  again,  but  could 
find  no  special  tenderness  anywhere.  She  was  simply  in  profound 
collapse.  A  general  diagnosis  of  "acute  abdomen"  was  all  that  could 
be  made,  but  with  a  strong  suspicion  of  a  perforating  ulcer,  or  possi- 
bly an  acute  hemorrhagic  pancreatitis.  After  this  she  required  very 
little  morphine,  but  the  stupor  persisted  and  deepened,  and  she  died 
a  little  before  midnight  on  the  eighteenth. 

After  entering  the  hosptial  she  had  no  more  vomiting,  nor  could 
we  get  any  movement  of  the  bowels.  Her  temperature  when  she 
entered  the  hospital  was  99.4°  F. ;  pulse,  120;  respiration,  14;  urine, 
normal.  Her  temperature  dropped  to  99°  F.,  then  rose  to  102.2°  F., 
and  the  next  day  to  103°.  Pulse  became  more  and  more  rapid,  and 
so  feeble  that  it  could  not  be  counted. 

Autopsy  the  next  morning  by  Dr.  Schilling  showed  the  intestines 
distended,  but  that  was  all.  Everything  in  the  abdomen  was  carefully 
examined,  but  nothing  could  be  found  wrong.     There  was  an  old  hy- 

45 


drosalpinx  on  the  one  side,  and  a  pyosalpinx  on  the  other,  but  no 
signs  of  any  pelvic  infection.  Lungs  and  heart  normal.  Cause  of 
death  absolutely  undetermined. 

2.  Baby  B.,  aged  one  year.  Patient  was  seen  in  consultation  with 
Dr.  Moore,  and  two  of  the  Columbus  Barracks'  surgeons.  Was  seen 
on  Monday  morning.  Had  been  ailing  since  the  preceding  Friday 
night.  Had  been  constipated  all  the  week.  Enemas  had  been  given 
without  any  effect.  Abdomen  not  distended.  The  child  had  vomited 
twice  before  the  doctors  saw  her,  and  had  vomited  again  since  that 
time.  On  Saturday  morning  was  having  clearly  abdominal  distress, 
but  no  acute  pain.  Vomited  that  morning.  Seemed  a  little  better  in 
the  afternoon.  No  medicine  was  given,  but  enemas.  No  bowel  move- 
ments. No  fever.  Breathing  rather  rapid,  with  a  grunting  expiration. 
Rapid  pulse.  Dr.  Moore  saw  the  case  in  consultation  the  next  day 
(Sunday),  and  thought  he  could  make  out  some  dullness  along  the 
ascending  colon.  No  nausea.  A  dose  of  oil  by  stomach  advised.  This 
was  given,  and,  in  due  time,  there  was  a  large  brownish  stool.  A  little 
more  oil  was  given  and  there  were  more  stools  later  in  the  night.  The 
first  movement  seemed  to  afford  a  little  relief,  but  after  that  the  stools 
produced  no  effect.  Considerable  gas  was  passed  during  the  night. 
Restless  all  night.  Monday  morning  not  so  well ;  very  tympanitic  and 
resistant  all  over  the  ascending  colon.  The  physicians  thought  there 
was  dullness  on  percussion  over  the  ascending  colon. 

I  found  the  patient  to  be  a  very  hearty  looking  little  girl,  rather 
plump.  Abdomen  distended,  but  I  could  localize  no  tender  point  by 
manipulation.  No  lump  anywhere.  Abdomen  generally  tympanitic. 
Free  escape  of  gas  while  I  was  manipulating.  Advised  against  any 
surgery.  Diagnosis  entirely  in  doubt.  Did  not  think  there  was  any 
appendicitis.  There  was  pretty  vigorous  peristalsis  at  this  time.  No 
signs  of  intussusception  or  volvulus.  I  saw  it  again  the  next  day,  as 
the  physicians  thought  they  could  feel  a  lump  rather  high  up  in  the  abdo- 
men on  the  right  side.  This  lump,  I  thought,  was  the  edge  of  the 
liver,  but,  to  be  sure,  gave  a  few  whiffs  of  chloroform  to  secure  re- 
laxation. This  showed  that  the  lump  was  the  right  lobe  of  the  liver. 
Took  advantage  of  the  opportunity  to  make  a  rectal  examination,  but 
this  was  entirely  negative.  The  child's  general  condition  continued 
about  the  same,  and  it  died  four  days  after  I  first  saw  it. 

Autopsy  was  made  with  unusual  thoroughness,  including  opening 
of  the  skull.     Absolutely  nothing  was  found  to  account  for  the  death. 

3.  Mrs.  H.  K.  Physician,  Dr.  C.  A.  Cooperrider.  March  1,  1915. 
Aged  thirty-eight  years.  Mother  of  three  children.  Had  always  en- 
joyed   excellent   health   until   some   months   before,   when   she   had   an 

46 


attack  of  inflammatory  rheumatism  from  which  she  made  a  good  re- 
covery. At  3  a,  m.  of  the  morning  of  m}^  visit  she  was  taken  suddenly 
with  severe  abdominal  pain.  Had  been  suffering  all  the  day  before 
and  during  the  night  with  sick  headache,  to  which  she  was  accus- 
tomed. This  sudden  pain  was  at  the  pit  of  the  stomach.  She  vomited, 
throwing  up  some  water,  which  she  had  taken.  As  Dr.  Cooperrider 
lived  at  some  distance,  a  neighboring  physician  was  called  in  who  made 
a  diagnosis  of  indigestion.  He  gave  her  a  hypodermic  and  ordered 
a  cathartic.  He  saw  her  again  during  the  forenoon  and  her  condition 
was  no  better.  Dr.  Cooperrider  was  called  at  3  p.  m.  He  found  her 
desperately  sick;  as  soon  as  possible  he  telephoned  me,  and  I  saw  her 
in  consultation  at  5  :30  p.  m. 

Found  patient  to  be  a  plump  woman  with  a  greatly  distended  abdo- 
men. Tender  all  over  the  abdomen,  but  particularly  on  the  right, 
above  the  umbilicus.  Here  she  said  she  felt  more  pain  than  anywhere 
else.  Flushed  face.  Slight  elevation  of  temperature.  Pulse,  160  to 
170,  and  almost  imperceptible.  Could  not  count  it  except  by  listening 
to  the  heart.  Diagnosis,  "acute  abdomen,"  but  because  of  her  age 
and  the  previous  history  there  was  a  suspicion  of  gall-stones,  and  per- 
haps acute  hemorrhagic  pancreatitis.  No  history  indicating  ulcer  of 
the  stomach  or  duodenum.  The  priest  was  present,  and  he  was  ad- 
vised to  administer  the  last  rites  of  the  church,  which  he  did.  Patient 
died  at  midnight. 

Autopsy  at  10:00  a.  m.  The  uterus  was  found  considerably  enlarged, 
containing  a  greatly  thickened  endometrium,  etc.  Aside  from  this  could 
find  nothing  pathological.  Diagnosis  absolutely  in  doubt.  Dr.  Cooper- 
rider, who,  after  the  consultation,  had  devoted  a  good  deal  of  thought  to 
the  study  of  the  subject,  had  fully  expected  to  find  acute  hemorrhagic 
pancreatitis. 

4.  Mr.  R.,  aged  forty-nine  years.  Physician,  Dr.  S.  D.  Stevenson. 
Patient  was  brought  into  the  hospital  hurriedly  on  April  3,  1914,  by 
Dr.  Goodman,  who  had  just  been  called  to  see  him  in  consultation. 
He  found  him  in  collapse,  and  after  bringing  him  to  the  hospital,  asked 
me  to  see  him  to  see  if  an  operation  was  possible.  I  went  over  at 
once,  but  was  met  by  the  nurse  on  the  stairs  with  the  statement  that 
the  patient  had  just  died. 

The  history  showed  that  some  days  before  the  patient  had  had  a 
right-sided  pneumonia.  Temperature,  104°  F.  Normal  crisis  on  the 
sixth  day.  Convalescence  was  ideal.  Temperature  remained  normal 
for  three  days.  On  the  morning  of  the  fourth  day  after  the  crisis  the 
patient  complained  •  of  some  uneasiness  in  the  abdomen,  but  nothing 
that  was  at  all  serious.     There  was  no   distention  and  practically  no 

47 


tenderness.  About  4:00  p.  m.  the  doctor  was  called  again  and  found 
him  in  collapse.  Abdomen  enormously  distended.  Was  removed  to 
the  hospital  at  once.  His  temperature  on  entering  was  96.6°  F.,  pulse, 
80;  respirations,  40.  Several  enemas  were  given,  but  with  very  little 
result.     He  died  two  hours  after  entering  the  hospital. 

Autopsy  by  Dr.  Schilling  showed  the  pneumonia  to  be  undergoing 
absolutely  normal  resolution  for  that  period.  Aside  from  that  and  the 
distended  intestines,   nothing  whatever  could  be  found  wrong. 

These  four  cases  are  reported  as  showing  the  uncertainties  of  diag- 
nosis, and  the  surprises  which  we  may  meet  with  in  autopsies.  In 
the  three  adults,  certainly  we  would  have  expected  to  find  marked 
pathological  developments  in  the  abdomen,  and  yet  nothing  whatever 
was  found.  The  symptoms  in  the  child  were  less  fulminant,  but  that 
is  so  frequently  the  case  with  children,  especially  in  appendicitis,  that 
the  absence  of  acute  symptoms  would  not  be  of  much  significance. 

It  is  somewhat  appalling  to  think  what  would  have  happened  in 
these  cases  had  operative  intervention  been  advised.  Nothing  would 
have  been  found,  no  good  would  have  been  accomplished,  and,  in  all, 
the  final  death  would  more  than  likely  have  been  attributed  to  the 
blunders  of  the  surgeon  in  advising  operation. — Cin.  Lancet-Clinic, 
Nov.  28,  1915. 


48 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  rules  of  the  Library  or  by  special  arrange- 
ment with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28(lt4l)M100 

.  xx\U\ 


